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Emergency medical services (EMS), also known as ambulance services or paramedic services, are
emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other
initialisms such as EMAS or EMARS.
In most places, the EMS can be summoned by members of the public (as well as medical facilities, other emergency services, businesses and authorities) via an
emergency telephone number
Most public switched telephone networks have a single emergency telephone number (sometimes known as the universal emergency telephone number or the emergency services number) that allows a caller to contact local emergency services for assis ...
which puts them in contact with a control facility, which will then dispatch a suitable resource for the situation.
Ambulance
An ambulance is a medically equipped vehicle which transports patients to treatment facilities, such as hospitals. Typically, out-of-hospital medical care is provided to the patient during the transport.
Ambulances are used to respond to medi ...
s are the primary vehicles for delivering EMS, though some also use
squad cars,
motorcycles
A motorcycle (motorbike, bike, or trike (if three-wheeled)) is a two or three-wheeled motor vehicle steered by a handlebar. Motorcycle design varies greatly to suit a range of different purposes: long-distance travel, commuting, cruising ...
,
aircraft
An aircraft is a vehicle that is able to fly by gaining support from the air. It counters the force of gravity by using either static lift or by using the dynamic lift of an airfoil, or in a few cases the downward thrust from jet engine ...
, or
boats
A boat is a watercraft of a large range of types and sizes, but generally smaller than a ship, which is distinguished by its larger size, shape, cargo or passenger capacity, or its ability to carry boats.
Small boats are typically found on inl ...
. EMS agencies may also operate a non-emergency
patient transport service, and some have
rescue squad
A rescue squad is an emergency service that provides technical rescue services, and may also provide emergency medical services and firefighting services. Rescue squads may be standalone organizations or an integrated part of fire department ...
s to provide
technical rescue
Technical rescue is the use of specialised tools and skills for rescue, including vehicle extrication, confined space rescue, rope rescue, trench rescue, structural collapse rescue, water rescue, and wilderness search and rescue. These often requi ...
services.
As a first resort the EMS provide treatment on the scene to those in need of
urgent medical care. If it is deemed necessary, they are tasked with transferring the
patient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other hea ...
to the next
point of care
Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care.
Clinical documentation
Clinical documentation is a record of the critical thinking and judgment of a heal ...
. This is most likely an
emergency department of a
hospital. Historically, ambulances only transported patients to care, and this remains the case in parts of the developing world.
The term "emergency medical service" was popularised when these services began to emphasise diagnosis and treatment at the scene. In some countries, a substantial portion of EMS calls do not result in a patient being taken to hospital.
Training and
qualification
Qualification is either the process of qualifying for an achievement, or a credential attesting to that achievement, and may refer to:
* Professional qualification, attributes developed by obtaining academic degrees or through professional exper ...
levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive ambulances, with no medical training.
[ In contrast, most systems have personnel who retain at least basic ]first aid
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial in ...
certifications, such as basic life support
Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be p ...
(BLS). In English-speaking countries, they are known as emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics a ...
s (EMTs) and paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
s, with the latter having additional training such as advanced life support
Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).
Components
These include:
* Tracheal in ...
(ALS) skills. Physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
s and nurse
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health c ...
s also provide pre-hospital care to varying degrees in different countries.
History
Precursors
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament
The New Testament grc, Ἡ Καινὴ Διαθήκη, transl. ; la, Novum Testamentum. (NT) is the second division of the Christian biblical canon. It discusses the teachings and person of Jesus, as well as events in first-century Chri ...
contains the parable of the Good Samaritan
The parable of the Good Samaritan is told by Jesus in the Gospel of Luke. It is about a traveler (implicitly understood to be Jewish) who is stripped of clothing, beaten, and left half dead alongside the road. First, a Jewish priest and then ...
, in which a man who has been beaten is cared for by a passing Samaritan. Luke 10:34 (NIV) – "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." During the Middle Ages, the Knights Hospitaller
The Order of Knights of the Hospital of Saint John of Jerusalem ( la, Ordo Fratrum Hospitalis Sancti Ioannis Hierosolymitani), commonly known as the Knights Hospitaller (), was a medieval and early modern Catholic military order. It was headq ...
were known for rendering assistance to wounded soldiers in the battlefield.
The first use of the ambulance as a specialized vehicle, in battle came about with the ''ambulances volantes'' designed by Dominique Jean Larrey
Baron Dominique Jean Larrey (; 8 July 1766 – 25 July 1842) was a French surgeon and military doctor, who distinguished himself in the French Revolutionary Wars and the Napoleonic Wars. An important innovator in battlefield medicine and triage, ...
(1766–1842), Napoleon Bonaparte
Napoleon Bonaparte ; it, Napoleone Bonaparte, ; co, Napulione Buonaparte. (born Napoleone Buonaparte; 15 August 1769 – 5 May 1821), later known by his regnal name Napoleon I, was a French military commander and political leader wh ...
's chief surgeon. Larrey was present at the battle of Spires, between the French and Prussia
Prussia, , Old Prussian: ''Prūsa'' or ''Prūsija'' was a German state on the southeast coast of the Baltic Sea. It formed the German Empire under Prussian rule when it united the German states in 1871. It was ''de facto'' dissolved by an ...
ns, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse
The horse (''Equus ferus caballus'') is a domesticated, one-toed, hoofed mammal. It belongs to the taxonomic family Equidae and is one of two extant subspecies of ''Equus ferus''. The horse has evolved over the past 45 to 55 million yea ...
-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield ''after'' they had received early treatment in the field.[ Larrey's projects for 'flying ambulances' were first approved by the Committee of Public Safety in 1794. Larrey subsequently entered Napoleon's service during the Italian campaigns in 1796, where his ambulances were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even developing a litter which could be carried by a camel for a campaign in ]Egypt
Egypt ( ar, مصر , ), officially the Arab Republic of Egypt, is a transcontinental country spanning the northeast corner of Africa and southwest corner of Asia via a land bridge formed by the Sinai Peninsula. It is bordered by the Medit ...
.[
]
Early civilian ambulances
A major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832. The statement on the carriage, as printed in ''The Times
''The Times'' is a British daily national newspaper based in London. It began in 1785 under the title ''The Daily Universal Register'', adopting its current name on 1 January 1788. ''The Times'' and its sister paper '' The Sunday Times'' (f ...
'', said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other".[ This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.
]
The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati
Cincinnati ( ) is a city in the U.S. state of Ohio and the county seat of Hamilton County. Settled in 1788, the city is located at the northern side of the confluence of the Licking and Ohio rivers, the latter of which marks the state line wit ...
, Ohio
Ohio () is a state in the Midwestern region of the United States. Of the fifty U.S. states, it is the 34th-largest by area, and with a population of nearly 11.8 million, is the seventh-most populous and tenth-most densely populated. The sta ...
(now the Cincinnati General) by 1865.[ This was soon followed by other services, notably the New York service provided out of ]Bellevue Hospital
Bellevue Hospital (officially NYC Health + Hospitals/Bellevue and formerly known as Bellevue Hospital Center) is a hospital in New York City and the oldest public hospital in the United States. One of the largest hospitals in the United States ...
which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine
Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. T ...
, and brandy, reflecting contemporary medicine.
Another early ambulance service was founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna
en, Viennese
, iso_code = AT-9
, registration_plate = W
, postal_code_type = Postal code
, postal_code =
, timezone = CET
, utc_offset = +1
, timezone_DST ...
after the disastrous fire at the Vienna Ringtheater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide.
In June 1887 the St John Ambulance Brigade
St John Ambulance is the name of a number of affiliated organisations in different countries which teach and provide first aid and emergency medical services, and are primarily staffed by volunteers. The associations are overseen by the internat ...
was established to provide first aid and ambulance services at public events in London
London is the capital and List of urban areas in the United Kingdom, largest city of England and the United Kingdom, with a population of just under 9 million. It stands on the River Thames in south-east England at the head of a estuary dow ...
. It was modelled on a military-style command and discipline structure.
Motorization
Also in the late 19th century, the automobile
A car or automobile is a motor vehicle with wheels. Most definitions of ''cars'' say that they run primarily on roads, seat one to eight people, have four wheels, and mainly transport people instead of goods.
The year 1886 is regarde ...
was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline
Gasoline (; ) or petrol (; ) (see ) is a transparent, petroleum-derived flammable liquid that is used primarily as a fuel in most spark-ignited internal combustion engines (also known as petrol engines). It consists mostly of organi ...
, and electricity
Electricity is the set of physical phenomena associated with the presence and motion of matter that has a property of electric charge. Electricity is related to magnetism, both being part of the phenomenon of electromagnetism, as describ ...
, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital
Michael Reese Hospital and Medical Center was an American hospital located in the Bronzeville neighborhood of Chicago, Illinois. Founded in 1881, Michael Reese Hospital was a major research and teaching hospital and one of the oldest and largest ...
, Chicago
(''City in a Garden''); I Will
, image_map =
, map_caption = Interactive Map of Chicago
, coordinates =
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, subdivision_name ...
, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899.[ This was followed in 1900 by New York City, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2 hp motors on the rear axle.][
During ]World War I
World War I (28 July 1914 11 November 1918), often abbreviated as WWI, was one of the deadliest global conflicts in history. Belligerents included much of Europe, the Russian Empire, the United States, and the Ottoman Empire, with fightin ...
, further advances were made in providing care before and during transport; traction splint
A traction splint most commonly refers to a splinting device that uses straps attaching over the pelvis or hip as an anchor, a metal rod(s) to mimic normal bone stability and limb length, and a mechanical device to apply traction (used in an at ...
s were introduced during the war and were found to have a positive effect on the morbidity
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
and mortality of patients with leg fractures. Two-way radio
A two-way radio is a radio that can both transmit and receive radio waves (a transceiver), unlike a broadcast receiver which only receives content. It is an audio (sound) transceiver, a transmitter and receiver in one unit, used for bidirection ...
s became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Prior to World War II
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposing ...
, there were some areas where a modern ambulance carried advanced medical equipment, was staffed by a physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
, and was dispatched by radio. In many locations, however, ambulances were hearse
A hearse is a large vehicle, originally a horse carriage but later with the introduction of motor vehicles, a car, used to carry the body of a deceased person in a coffin at a funeral, wake, or memorial service. They range from deliberately a ...
s, the only available vehicle that could carry a recumbent patient, and were thus frequently run by funeral home
A funeral home, funeral parlor or mortuary, is a business that provides burial and funeral services for the dead and their families. These services may include a prepared wake and funeral, and the provision of a chapel for the funeral.
Services ...
s. These vehicles, which could serve either purpose, were known as combination cars.[Kuehl, Alexander E. (Ed.). ''Prehospital Systems and Medical Oversight'', 3rd edition. ''National Association of EMS Physicians''. 2002.]
Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.
Rise of modern EMS
Advances in the 1960s, especially the development of CPR
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore sponta ...
and defibrillation as the standard form of care for out-of-hospital cardiac arrest
Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and poss ...
, along with new pharmaceutical
A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field an ...
s, led to changes in the tasks of the ambulances. In Belfast
Belfast ( , ; from ga, Béal Feirste , meaning 'mouth of the sand-bank ford') is the capital and largest city of Northern Ireland, standing on the banks of the River Lagan on the east coast. It is the 12th-largest city in the United Kingdom ...
, Northern Ireland
Northern Ireland ( ga, Tuaisceart Éireann ; sco, label= Ulster-Scots, Norlin Airlann) is a part of the United Kingdom, situated in the north-east of the island of Ireland, that is variously described as a country, province or region. Nort ...
the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. Freedom House Ambulance Service
Freedom House Ambulance Service was the first emergency medical services, emergency medical service in the United States to be staffed by paramedics with medical training beyond basic first aid. Founded in 1967 to serve the predominantly black Hi ...
was the first civilian emergency medical service in the United States to be staffed by paramedics
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
, most of which were black.
One well-known report in the US during that time was '' Accidental Death and Disability: The Neglected Disease of Modern Society'', also known as ''The White Paper''. The report concluded that ambulance services in the US varied widely in quality and were often unregulated and unsatisfactory. These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. The government reports resulted in the creation of standard Standard may refer to:
Symbols
* Colours, standards and guidons, kinds of military signs
* Standard (emblem), a type of a large symbol or emblem used for identification
Norms, conventions or requirements
* Standard (metrology), an object th ...
s 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), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.
In 1971 a progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a "superb white paper" that "jolted and wakened the entire structure of organized medicine." This report is created as a "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services". Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting. Such advancements included Dr. R Adams Cowley
R Adams Cowley (July 25, 1917 – October 27, 1991) was an American surgeon considered a pioneer in emergency medicine and the treatment of Shock (circulatory), shock Physical trauma, trauma. Called the "Father of Trauma Medicine", he was the foun ...
creating the country's first statewide EMS program, in Maryland
Maryland ( ) is a state in the Mid-Atlantic region of the United States. It shares borders with Virginia, West Virginia, and the District of Columbia to its south and west; Pennsylvania to its north; and Delaware and the Atlantic Ocean to ...
.
The developments were paralleled in other countries. In the United Kingdom, a 1973 law merged the municipal ambulance services into larger agencies and set national standards. In France, the first official SAMU agencies were founded in the 1970s.
Organization
Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization. This variation may lead to large differences in levels of care and expected scope of practice. Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.
Government ambulance service
Operating separately from (although alongside) the fire and police services of the area, these ambulances are funded by local, provincial or national governments. In some countries, these only tend to be found in big cities, whereas in countries such as the United Kingdom, almost all emergency ambulances are part of a national health system.
In the United States, ambulance services provided by a local government are often referred to as "third service" EMS (the fire department, police department, and separate EMS forming an emergency services trio) by the employees of said service, as well as other city officials and residents. The most notable examples of this model in the United States are Pittsburgh Bureau of Emergency Medical Services (PEMS), Boston EMS, New Orleans Emergency Medical Services
Austin-Travis County Emergency Medical Services
Cleveland EMS
Wake County Emergency Medical Services
an
. Government ambulance services also have to take civil service exams just like government fire departments and police. In the United States, certain federal government agencies employ emergency medical technicians at the basic and advanced life support levels, such as the National Park Service
The National Park Service (NPS) is an agency of the United States federal government within the U.S. Department of the Interior that manages all national parks, most national monuments, and other natural, historical, and recreational propert ...
and the Federal Bureau of Prisons
The Federal Bureau of Prisons (BOP) is a United States federal law enforcement agency under the Department of Justice that is responsible for the care, custody, and control of incarcerated individuals who have committed federal crimes; that i ...
.
Fire- or police-linked service
In countries such as the United States, Japan, France, South Korea and parts of India, ambulances can be operated by the local fire or police services. Fire-based EMS is the most common model in the United States, where nearly all urban fire departments provide EMS and a majority of emergency transport ambulance services in large cities are part of fire departments. It is somewhat rare for a police department in the United States to provide EMS or ambulance services, although many police officers have basic medical training. One notable example is New Orleans Emergency Medical Services, which was formed as a hospital-based service, was operated by the New Orleans Police Department
The New Orleans Police Department (NOPD) has primary responsibility for law enforcement in New Orleans, Louisiana. The department's jurisdiction covers all of Orleans Parish, while the city is divided into eight police districts.
The NOPD has ...
from 1947 to 1985, and is currently operated by the New Orleans Health Department and the New Orleans Office of Homeland Security and Emergency Preparedness, separate from the New Orleans Fire Department
The New Orleans Fire Department provides fire protection and first responder emergency medical services to the city of New Orleans, Louisiana. The department serves 378,715 people living in a area, including of water.
History
The NOFD got its s ...
.
Charity ambulance service
Charities or non-profit companies operate some emergency medical services. They are primarily staffed by volunteers
Volunteering is a voluntary act of an individual or group freely giving time and labor for community service. Many volunteers are specifically trained in the areas they work, such as medicine, education, or emergency rescue. Others serve ...
, though some have paid personnel. These may be linked to a volunteer fire service
A fire department (American English) or fire brigade (Commonwealth English), also known as a fire authority, fire district, fire and rescue, or fire service in some areas, is an organization that provides fire prevention and fire suppression se ...
, and some volunteers may provide both services. Some ambulance charities specialize in providing cover at public gatherings and events (e.g. sporting events), while others provide care to the wider community.
The International Red Cross and Red Crescent Movement is the largest charity in the world that provides emergency medicine. (in some countries, it operates as a private ambulance service). Other organisations include St John Ambulance
St John Ambulance is the name of a number of affiliated organisations in different countries which teach and provide first aid and emergency medical services, and are primarily staffed by volunteers. The associations are overseen by the internat ...
, the Order of Malta Ambulance Corps
The Order of Malta Ireland – Ambulance Corps is a voluntary ambulance and first aid organisation operating in Ireland in affiliation with the Sovereign Military Order of Malta, founded in 1938.
Its purposes include teaching first aid, prov ...
and Hatzalah
Hatzalah (; he, הַצָּלָה, lit=rescue, relief) is one of several Jewish volunteer emergency medical service (EMS) organizations serving mostly areas with Jewish communities around the world, giving free medical service no matter their ...
, as well as small local volunteer agencies. In the United States, volunteer ambulances are rarer, but can still be seen in both metropolitan and rural areas (e.g. Hatzalah
Hatzalah (; he, הַצָּלָה, lit=rescue, relief) is one of several Jewish volunteer emergency medical service (EMS) organizations serving mostly areas with Jewish communities around the world, giving free medical service no matter their ...
). Charities such as BASICS Scotland
The British Association for Immediate Care Scotland (BASICS Scotland) is an organisation involved with prehospital care. It has the aims of providing encouragement and aid with the formation of immediate care schemes and to provide training to s ...
, specialise in facilitating training medical professionals to volunteer to assist the statutory ambulance services in the care of patients, through their attendance at those with serious illnesses or injuries.
A few charities provide ambulances for taking patients on trips or vacations away from hospitals, hospices or care homes where they are in long-term care. Examples include the UK's Jumbulance project.
Private ambulance service
Some ambulances are operated by commercial companies with paid employees, usually on a contract to the local or national government, Hospital Networks, Health Care Facilities and Insurance Companies.
In the USA private ambulance companies provide 911 emergency services in large cities as well as most rural areas by contracting with local governments. In areas that the local County or City provide their own 911 service, private companies provide discharges and transfers from hospitals and to/from other health related facilities and homes. In most areas private companies are part of the local government Emergency Disaster plan, and are relied upon heavily for the overall EMS response, treatment and recovery.
In some areas, private companies may provide only the patient transport elements of ambulance care (i.e. non-urgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility-impaired if they have for example fallen and simply need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available at all times for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events. In Latin America, private ambulance companies are often the only readily-available EMS service
Combined emergency service
These are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where demand or budget is too low to support separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.
Hospital-based service
Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital.
Internal ambulances
Many large factories and other industrial centres, such as chemical plants, oil refineries
An oil refinery or petroleum refinery is an industrial process plant where petroleum (crude oil) is transformed and refined into useful products such as gasoline (petrol), diesel fuel, asphalt base, fuel oils, heating oil, kerosene, lique ...
, breweries and distilleries
Distillation, or classical distillation, is the process of separating the components or substances from a liquid mixture by using selective boiling and condensation, usually inside an apparatus known as a still. Dry distillation is the heat ...
have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion.
Purpose
Emergency medical services exists to fulfill the basic principles of first aid
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial in ...
, which are to Preserve Life, Prevent Further Injury, and Promote Recovery.
This common theme in medicine
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pr ...
is demonstrated by the "star of life". The Star of Life
The Star of Life is a symbol used to identify emergency medical services. It features a blue six-pointed star outlined by a white border. The middle contains a Rod of Asclepius – an ancient symbol of medicine. The Star of Life can be found on a ...
shown here, where each of the 'arms' to the star represent one of the six points, are used to represent the six stages of high quality pre-hospital care, which are:
#Early detection – members of the public, or another agency, find the incident and understand the problem
# Early reporting – the first persons on scene make a call to the emergency medical services (911) and provide details to enable a response to be mounted
# Early response – the first professional (EMS) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin
# Good on-scene/field care – the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.
# Care in transit -– the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
# Transfer to definitive care – the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians
Strategies for delivering care
Although a variety of differing philosophical
Philosophy (from , ) is the systematized study of general and fundamental questions, such as those about existence, reason, knowledge, values, mind, and language. Such questions are often posed as problems to be studied or resolved. Some ...
approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
-led and the other led by pre-hospital allied health staff such as emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics a ...
s or paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
s. These models are commonly referred to as the Franco-German model and Anglo-American model.
Studies have been inconclusive as to whether one model delivers better results than the other. A 2010 study in the Oman Medical Journal
The ''Oman Medical Journal'' is a bimonthly open access peer-reviewed medical journal. It was established in 1984 and published by the Oman Medical Specialty Board. At the start of 2020, Oman Medical Journal transitioned from a print-publicatio ...
suggested that rapid transport was a better strategy for trauma cases, while stabilization at the scene was a better strategy for cardiac arrests.
Levels of care
Many systems have tiers of response for medical emergencies. For example, a common arrangement in the United States is that fire engines or volunteers are sent to provide a rapid initial response to a medical emergency, while an ambulance is sent to provide advanced treatment and transport the patient. In France, fire service and private company ambulances provide basic care, while hospital-based ambulances with physicians on board provide advanced care. In many countries, an air ambulance
Air medical services is a comprehensive term covering the use of air transportation, aeroplane or helicopter, to move patients to and from healthcare facilities and accident scenes. Personnel provide comprehensive prehospital and emergency and cri ...
provides a higher level of care than a regular ambulance.
Examples of level of care include:
*First aid
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial in ...
consists of basic skills that are commonly taught to members of the public, such as cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spon ...
, bandaging wounds and saving someone from choking
Choking, also known as foreign body airway obstruction (FBAO), is a phenomenon that occurs when breathing is impeded by a blockage inside of the respiratory tract. An obstruction that prevents oxygen from entering the lungs results in oxygen dep ...
.
*Basic Life Support
Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be p ...
(BLS) is often the lowest level of training that can be held by those who treat patients on an ambulance. Commonly, it includes administering oxygen therapy, some drugs and a few invasive treatments. BLS personnel may either operate a BLS ambulance on their own, or assist a higher qualified crewmate on an ALS ambulance. In English-speaking countries, BLS ambulance crew are known as emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics a ...
s or emergency care assistant
An emergency care assistant (ECA) is a type of NHS ambulance service worker in the United Kingdom, often used to support paramedics in responding to emergency calls.
This frontline staff role was introduced in 2006 as part of the modernisation of ...
s.
* Intermediate Life Support (ILS), also known as Limited Advanced Life Support (LALS), is positioned between BLS and ALS but is less common than both. It is commonly a BLS provider with a moderately expanded skill set, but where it is present it usually replaces BLS.
*Advanced Life Support
Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).
Components
These include:
* Tracheal in ...
(ALS) has a considerably expanded range of skills such as intravenous therapy, cricothyrotomy
A cricothyrotomy (also called cricothyroidotomy) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, o ...
and interpreting an electrocardiogram. The scope of this higher tier response varies considerably by country. Paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
s commonly provide ALS, but some countries require it to be a higher level of care and instead employ physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
s in this role. Additionally Advanced Life Support includes administering therapeutic doses of electrical shock to those who are in cardiac arrest or using drugs to stimulate the heart, Airway therapy, and so on and so forth. Most ambulances are equipped with advanced Life Support equipment and have paramedics on board. While some fire departments have ambulances, first aid and squads utilize ambulances for emergency medical services.
*Critical Care Transport (CCT), also known as medical retrieval or rendez vous MICU protocol in some countries (Australia, NZ, Great Britain, and Francophone Canada) refers to the critical care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in regionalized systems of hospital care where intensive care services are centralized to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service
The Emergency Medical Retrieval Service (EMRS) provides aeromedical critical care to people in Scotland. It provides patients in remote and rural areas with rapid access to the skills of a consultant in emergency medicine, intensive care medic ...
in Scotland. This level of care is likely to involve traditional healthcare professionals (in addition to or instead of critical care-trained paramedics), meaning nurses
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health c ...
and/or physicians working in the pre-hospital setting and even on ambulances.
Transport-only
The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was historically the case in all countries. It remains the case in much of the developing world, where operators as diverse as taxi drivers[ and undertakers may transport people to hospital.
]
Transport-centered EMS
The Anglo-American model is also known as "load and go" or "scoop and run". In this model, ambulances are staffed by paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
s and/or emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics a ...
s. They have specialized medical training, but not to the same level as a physician. In this model it is rare to find a physician actually working routinely in ambulances, although they may be deployed to major or complex cases. The physicians who work in EMS provide oversight
Oversight may refer to:
Governance
*Regulation – rulemaking
*Separation of powers in state governance (checks and balances) - the concept of separate branches of government or agencies exercising authority over one another
*Checks and control ...
for the work of the ambulance crews. This may include off-line medical control, where they devise protocols
Protocol may refer to:
Sociology and politics
* Protocol (politics), a formal agreement between nation states
* Protocol (diplomacy), the etiquette of diplomacy and affairs of state
* Etiquette, a code of personal behavior
Science and technology ...
or 'standing orders' (procedures for treatment). This may also include on-line medical control, in which the physician is contacted to provide advice and authorization for various medical interventions.
In some cases, such as in the UK, South Africa and Australia, a paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
may be an autonomous health care professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient. Recently "Telemedicine" has been making an appearance in ambulances. Similar to online medical control, this practice allows paramedics to remotely transmit data such as vital signs and 12 and 15 lead ECGs to the hospital from the field. This allows the emergency department to prepare to treat patients prior to their arrival. This is allowing lower level providers (Such as EMT-B) in the United States to utilize these advanced technologies and have the doctor interpret them, thus bringing rapid identification of rhythms to areas where paramedics are stretched thin. While most insurance companies only reimburse EMS providers for transporting patients to 911 receiving facilities (e.g. Emergency Departments
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...
),the Center to Medicare and Medicaid Services is in the process of evaluating a payment model to enable reimbursement for patients evaluated and treated on-scene.
Major trauma
The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC
Medical evacuation, often shortened to medevac or medivac, is the timely and efficient movement and en route care provided by medical personnel to wounded being evacuated from a battlefield, to injured patients being evacuated from the scene of a ...
aeromedical evacuation helicopter
A helicopter is a type of rotorcraft in which lift and thrust are supplied by horizontally spinning rotors. This allows the helicopter to take off and land vertically, to hover, and to fly forward, backward and laterally. These attributes ...
, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit
Emergency medical services in France are provided by a mix of organizations under public health control. The central organizations that provide these services are known as a SAMU, which stands for (Urgent Medical Aid Service). Local SAMU organis ...
or the German "Notarzt"-System (preclinical emergency physician).
The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure ''a''irway, ''b''reathing and ''c''irculation; external bleeding control; endotracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently ...
) and the victim is transported as fast as possible to a trauma centre
A trauma center (or trauma centre) is a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may also refer to an emergenc ...
.
The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma
Trauma most often refers to:
* Major trauma, in physical medicine, severe physical injury caused by an external source
* Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic i ...
, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tra ...
(STEMI
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient. Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab. The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent. In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.
Physician-led EMS
Physician-led EMS is also known as the Franco-German model, "stay and play", "stay and stabilize" or "delay and treat". In a physician-led system, doctors respond directly to all major emergencies requiring more than simple first aid
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial in ...
. The physicians will attempt to treat casualties at the scene and will only transport them to hospital if it is deemed necessary. If patients are transported to hospital, they are more likely to go straight to a ward rather than to an emergency department. Countries that use this model include Austria, France, Belgium, Luxembourg, Italy, Spain, Brazil and Chile.
In some cases in this model, such as France, there is no direct equivalent to a paramedic. Physicians and (in some cases) nurses
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health c ...
provide all medical interventions for the patient. Other ambulance personnel are not non-medically trained and only provide driving and heavy lifting. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is an assistant to the physician with a restricted scope of practice
Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. The scope of practice is limited to that which the law allows for ...
. They are only permitted to perform Advanced Life Support
Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).
Components
These include:
* Tracheal in ...
(ALS) procedures if authorized by the physician, or in cases of immediate life-threatening conditions.[ ]Ambulances
An ambulance is a medically equipped vehicle which transports patients to treatment facilities, such as hospitals. Typically, out-of-hospital medical care is provided to the patient during the transport.
Ambulances are used to respond to medi ...
in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.
Personnel
Ambulance personnel are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.
A unique aspect of EMS is that there are two hierarchies of authority, as the chain of command
A command hierarchy is a group of people who carry out orders based on others' authority within the group. It can be viewed as part of a power structure, in which it is usually seen as the most vulnerable and also the most powerful part.
Milit ...
is separate to medical authority.
Basic life support (BLS)
First responder
Certified first responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, cardio-pulmonary resuscitation (CPR), and automated external defibrillator
An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation (VF) and pulseless ventricular tachycardia, and is able to treat them thro ...
(AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an emergency call
Most public switched telephone networks have a single emergency telephone number (sometimes known as the universal emergency telephone number or the emergency services number) that allows a caller to contact local emergency services for assista ...
. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before the ambulance arrives, and to then assist the ambulance crew.
Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include Community First Responder
A Community first responder (CFR), is a person available to be dispatched by an ambulance control centre to attend medical emergencies in their local area. They can be members of the public, who have received training in life-saving interventions s ...
schemes run by ambulance services the UK and similar volunteer schemes operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as rescue squad
A rescue squad is an emergency service that provides technical rescue services, and may also provide emergency medical services and firefighting services. Rescue squads may be standalone organizations or an integrated part of fire department ...
s. Police officer
A police officer (also called a policeman and, less commonly, a policewoman) is a warranted law employee of a police force. In most countries, "police officer" is a generic term not specifying a particular rank. In some, the use of the ...
s and firefighters who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level.
Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The International Red Cross and Red Crescent Movement and St John Ambulance
St John Ambulance is the name of a number of affiliated organisations in different countries which teach and provide first aid and emergency medical services, and are primarily staffed by volunteers. The associations are overseen by the internat ...
both provide first aiders in these roles.
Driver
Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid and CPR certificates), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.
Non-emergency driver/attendant
Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom.
Emergency medical technician
Emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics a ...
s, also known as Ambulance Technicians in the UK and EMT in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I (EMT-A in some states) and EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. EMTs are usually able to perform a wide range of emergency care skills, such as automated defibrillation, care of spinal injuries and oxygen therapy. In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs (including but not limited to Epinephrine, Narcan, Oxygen, Aspirin, Nitroglycerin - dependent on country, state, and medical direction), more advanced airway procedures, CPAP, and limited cardiac monitoring. Most advanced procedures and skills are not within the national scope of practice for an EMT. As such most states require additional training and certifications to perform above the national curriculum standards. In the US, an EMT certification requires intense courses and training in field skills. A certification expires after two years and holds a requirement of taking 48 CEUs (continuing education credits). 24 of these credits must be in refresher courses while the other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric care, specific traumas, etc.
Emergency medical dispatcher
An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time
Response time may refer to:
*The time lag between an electronic input and the output signal which depends upon the value of passive components used.
* Responsiveness, how quickly an interactive system responds to user input
* Response time (biolog ...
by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.
Advanced life support (ALS)
Paramedic
A paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including cannulation
A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
(and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform endotracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently ...
), cardiac monitoring
Cardiac monitoring generally refers to continuous or intermittent monitoring of heart activity to assess a patient's condition relative to their cardiac rhythm. Cardiac monitoring is usually carried out using electrocardiography, which is a noninva ...
, ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...
, intubation
Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blake ...
, pericardiocentesis, cardioversion, thoracostomy
A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracosto ...
, and other skills such as performing a surgical cricothyrotomy
A cricothyrotomy (also called cricothyroidotomy) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, o ...
. The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification (FP-C
The Flight paramedic Certification (FP-C) is an advanced certification that indicates an individual has attained the designation of Certified Flight Paramedic. The FP-C certification exam is administered by thInternational Board of Specialty Cert ...
), and Critical Care Emergency Medical Transport Program certification.
Critical care paramedic
A critical care paramedic, also known as an advanced practice paramedic or specialist paramedic, is a paramedic with additional training to deal with critically ill patients.[ Critical care paramedics often work on ]air ambulances
Air medical services is a comprehensive term covering the use of air transportation, aeroplane or helicopter, to move patients to and from healthcare facilities and accident scenes. Personnel provide comprehensive prehospital and emergency and cri ...
, which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances. The training, permitted skills, and certification requirements vary from one jurisdiction to the next. It also varies to whether they are trained externally by a university or professional body or 'in house' by their EMS agency.
These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are dopamine, dobutamine
Dobutamine is a medication used in the treatment of cardiogenic shock (as a result of inadequate tissue perfusion) and severe heart failure. It may also be used in certain types of cardiac stress tests. It is given by IV only, as an injection in ...
, propofol, blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...
and blood products
A blood product is any therapeutic substance prepared from human blood. This includes whole blood; blood components; and plasma derivatives. Whole blood is not commonly used in transfusion medicine. Blood components include: red blood cell conce ...
to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump
The intra-aortic balloon pump (IABP) is a mechanical device that increases myocardial oxygen perfusion and indirectly increases cardiac output through afterload reduction. It consists of a cylindrical polyurethane balloon that sits in the aorta ...
(IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter
An umbilical line is a catheter that is inserted into one of the two arteries or the vein of the umbilical cord. Generally the UAC/UVC (Umbilical Artery Catheter/Umbilical Vein Catheter) is used in Neonatal Intensive Care Units (NICU) as it provid ...
), UACs ( Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
s.
Paramedic practitioner / emergency care practitioner
In the United Kingdom and South Africa, some serving paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
s receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics. An emergency care practitioner is a position that is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer-term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.
Traditional healthcare professions
Registered nurses
The use of registered nurses
A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to o ...
(RNs) in the pre-hospital setting is common in many countries in absence of paramedics. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed, as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.
In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In Estonia
Estonia, formally the Republic of Estonia, is a country by the Baltic Sea in Northern Europe. It is bordered to the north by the Gulf of Finland across from Finland, to the west by the sea across from Sweden, to the south by Latvia, a ...
60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands
)
, anthem = ( en, "William of Nassau")
, image_map =
, map_caption =
, subdivision_type = Sovereign state
, subdivision_name = Kingdom of the Netherlands
, established_title = Before independence
, established_date = Spanish Netherl ...
, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT. In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs. And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain. In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR units are staffed by physicians and nurses
Physician
In countries with a physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a paramedic
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
, as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions.
In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the air ambulance
Air medical services is a comprehensive term covering the use of air transportation, aeroplane or helicopter, to move patients to and from healthcare facilities and accident scenes. Personnel provide comprehensive prehospital and emergency and cri ...
s in the UK. They may also provide advice and devise protocols for treatment, with a medical director acting as the most senior medical adviser to the ambulance service. In the United States, EMS became an officially recognized subspecialty by the American Board of Emergency Medicine in 2010, and the first examinations were held in 2013. Many states now recommend EMS board certifiction for newly hired Medical Directors of EMS agencies.
Specialist EMS
Air ambulance
Air ambulances often complement a land ambulance service. In some remote areas, they may even form the primary ambulance service. Like many innovations in EMS, medical aircraft were first used in the military. One of the first recorded aircraft rescues of a casualty was in 1917 in Turkey
Turkey ( tr, Türkiye ), officially the Republic of Türkiye ( tr, Türkiye Cumhuriyeti, links=no ), is a transcontinental country located mainly on the Anatolian Peninsula in Western Asia, with a small portion on the Balkan Peninsula in ...
, when a soldier in the Camel Corps who had been shot in the ankle was flown to hospital in a de Havilland DH9
The Airco DH.9 (from de Havilland 9) – also known after 1920 as the de Havilland DH.9 – was a British single-engined biplane bomber developed and deployed during the First World War.
The DH.9 was a development of Airco's earlier successfu ...
. In 1928, the first civilian air medical service was founded in Australia to provide healthcare to people living in remote parts of the Outback. This service became the Royal Flying Doctor Service
The Royal Flying Doctor Service (RFDS), commonly known as the Flying Doctor, is an air medical service in Australia. It is a non-profit organisation that provides emergency and primary health care services for those living in rural, remote an ...
. The use of helicopters was pioneered in the Korean War
, date = {{Ubl, 25 June 1950 – 27 July 1953 (''de facto'')({{Age in years, months, weeks and days, month1=6, day1=25, year1=1950, month2=7, day2=27, year2=1953), 25 June 1950 – present (''de jure'')({{Age in years, months, weeks a ...
, when time to reach a medical facility was reduced from 8 hours to 3 hours in World War II
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposing ...
, and again to 2 hours by the Vietnam War
The Vietnam War (also known by other names) was a conflict in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. It was the second of the Indochina Wars and was officially fought between North Vietnam a ...
.
Aircraft can travel faster and operate in a wider coverage area than a land ambulance. They have a particular advantage for major trauma injuries. The well-established theory of the golden hour suggests that major trauma patients should be transported as quickly as possible to a specialist trauma center
A trauma center (or trauma centre) is a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may also refer to an emergen ...
. Therefore, medical responders in a helicopter can provide both a higher level of care at the scene, faster transport to a specialist hospital and critical care during the journey. A disadvantage is that it can be dangerous and potentially not possible for them to fly at night or in bad weather.
Tactical (hazardous area)
Some EMS agencies have set up specialist teams to help those injured in a major incident or a dangerous situation. These include tactical police operations, active shooter
Active shooter or active killer describes the perpetrator of a type of mass murder marked by rapidity, scale, randomness, and often suicide. The United States Department of Homeland Security defines an ''active shooter'' as "an individual acti ...
s, bombings, hazmat
Dangerous goods, abbreviated DG, are substances that when transported are a risk to health, safety, property or the environment. Certain dangerous goods that pose risks even when not being transported are known as hazardous materials ( syllabi ...
situations, building collapses, fires and natural disasters. In the US, these are often known as Tactical EMS teams and are often deployed alongside police SWAT teams. The equivalent in UK ambulance services is a Hazardous Area Response Team (HART).
Wilderness
Wilderness EMS-like systems (WEMS) have been developed to provide medical responses in remote areas, which may have significantly different needs to an urban area. Examples include the National Ski Patrol
The nonprofit National Ski Patrol (NSP) is the largest winter education organization in the world. The NSP provides education, outreach, and credentialing related to outdoor recreation and safety. It is currently composed of more than 31,000 memb ...
or the regional-responding Appalachian Search and Rescue Conference (USA based). Like traditional EMS providers, all wilderness emergency medical (WEM) providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the Wilderness Medical Society
The Wilderness Medical Society was created on 15 February 1983 by three physicians from California, United States — Dr. Paul Auerbach, Dr. Ed Geehr, and Dr. Ken Kizer. It is the largest international non-profit membership organization devoted ...
and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course, which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011. Skills taught in WEMT courses exceeding the EMT-Basic scope of practice include catheterization, antibiotic administration, use of intermediate Blind Insertion Airway Devices (i.e. King Laryngeal Tube), Nasogastric Intubation
Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the oesophagus, and down into the stomach. Orogastric intubation is a similar process involving the inserti ...
, and simple suturing; however, the scope of practice for the WEMT still falls under BLS level care. A multitude of organizations provide WEM training, including private schools, non-profit organizations such as the Appalachian Center for Wilderness Medicine and the Wilderness EMS Institute, military branches, community colleges and universities, EMS-college-hospital collaborations, and others.
Organization in different countries
* Emergency medical services in Austria
* Emergency medical services in Australia
* Emergency medical services in Brazil
*Emergency medical services in Canada
Emergency medical services in Canada are the responsibility of each Canadian province or territory. The services, including both ambulance and paramedic services, may be provided directly by the province, contracted to a private provider, o ...
* Emergency medical services in Finland
*Emergency medical services in France
Emergency medical services in France are provided by a mix of organizations under public health control. The central organizations that provide these services are known as a SAMU, which stands for (Urgent Medical Aid Service). Local SAMU organis ...
* Emergency medical services in Germany
* Emergency medical services in Hong Kong
* Emergency medical services in Iceland
* Emergency medical services in Iran
* Emergency medical services in Ireland
* Emergency medical services in Israel
*Emergency medical services in Italy
Emergency medical services in Italy currently consist primarily of a combination of volunteer organizations providing ambulance service, supplemented by physicians and nurses who perform all advanced life support (ALS) procedures. The emergency tel ...
* Emergency medical services in the Netherlands
* Emergency medical services in New Zealand
* Emergency medical services in Norway
* Emergency medical services in Pakistan
*Emergency medical services in Poland
State Medical Rescue ( pl, Państwowe Ratownictwo Medyczne, PRM) in Poland is a system of free public emergency healthcare established by ''Ustawa o Państwowym Ratownictwie Medycznym'' (''State Medical Rescue Act''), including ambulance service ...
*Emergency medical services in Portugal
Emergency medical services in Portugal are organized in three separate systems, one each covering Continental Portugal, the Azores and Madeira. The largest system is SIEM, which covers the territory of Continental Portugal.
The modern Portuguese ...
*Emergency medical services in Romania
SMURD is an emergency rescue service based in Romania. The name is the Romanian acronym for "Serviciul Mobil de Urgență, Reanimare și Descarcerare", which means ''Mobile Emergency Service for Resuscitation and Extrication''. It was created ...
* Emergency medical services in Russia
* Emergency medical services in Spain
*Emergency medical services in South Africa
Emergency medical services in South Africa are a public/private system aimed at the provision of emergency ambulance service, including emergency care and transportation to hospital.
Organization
Land Ambulance
Emergency ambulance service ...
* Emergency medical services in Sri Lanka
* Emergency medical services in Ukraine
*Emergency medical services in the United Kingdom
Emergency medical services in the United Kingdom provide emergency care to people with acute illness or injury and are predominantly provided free at the point of use by the four National Health Services (NHS) of England, Scotland, Wales, an ...
*Emergency medical services in the United States
In the United States, emergency medical services (EMS) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the National Highway Traffic Safety Administra ...
* Emergency medical services in Indonesia
* Emergency medical services in Turkey
See also
* Battlefield medicine
Battlefield medicine, also called field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first ...
* CEN 1789
CEN 1789:2020 is the European Union standard for ambulances and medical transportation vehicles. This European standard specifies requirements for the design, testing, performance and equipping of road ambulances used for the transport and care of ...
* First Aid Care Team, a rapid-response emergency unit in Chicago disbanded in 2005.
* Good Samaritan law
Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are, or whom they believe to be injured, ill, in peril, or otherwise incapacitated.[In case of emergency
In Case of Emergency (ICE) is a programme designed to enable first responders, such as paramedics, firefighters, and police officers, as well as hospital personnel, to contact the next of kin of the owner of a mobile phone in order to obtain imp ...]
, a programme that enables EMS workers to identify victims and contact their next of kin to obtain important medical information
* List of EMS provider credentials
* Mass Gathering Medicine
* Medical amnesty policy
* Public utility model, a model for organizing Emergency Medical Services
* Star of Life
The Star of Life is a symbol used to identify emergency medical services. It features a blue six-pointed star outlined by a white border. The middle contains a Rod of Asclepius – an ancient symbol of medicine. The Star of Life can be found on a ...
* The White Paper (Official title "Accidental Death and Disability: The Neglected Disease of Modern Society"a 1966 report that prompted the development of organized EMS in the US)
* Wilderness medicine
Wilderness medicine is a rapidly evolving field and is of increasing importance as more people engage in hiking, climbing, kayaking, and other potentially hazardous activities in the backcountry. The modern definition of wilderness medicine is "m ...
References
Further reading
*''Planning Emergency Medical Communications: Volume 2, Local/Regional Level Planning Guide'', (Washington, D.C.: National Highway Traffic Safety Administration, US Department of Transportation, 1995).
External links
*
"Emergency Medical Services in the European Union: report of an assessment project co-ordinated by the European Union"
{{DEFAULTSORT:Emergency Medical Services
Lifesaving