Ambulance
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An ambulance is a
Ambulances are generally considered emergency vehicles authorized to be equipped with emergency lights and sirens. Generally, vehicles count as an ambulance if they can transport patients. However, it varies by jurisdiction as to whether a non-emergency patient transport vehicle (also called an ambulette) is counted as an ambulance. These vehicles are not usually (although there are exceptions) equipped with life-support equipment, and are usually crewed by staff with fewer qualifications than the crew of emergency ambulances. Conversely, EMS agencies may also have nontransporting EMS vehicles that cannot transport patients.[2]
The term ambulance comes from the Latin word "ambulare" as meaning "to walk or move about"[3] which is a reference to early medical care where patients were moved by lifting or wheeling. The word originally meant a moving hospital, which follows an army in its movements.[4] Ambulances (ambulancias in Spanish) were first used for emergency transport in 1487 by the Spanish forces during the siege of Málaga by the Catholic Monarchs against the Emirate of Granada. During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons.[5] Field hospitals were still called ambulances during the Franco-Prussian War[6] of 1870 and in the Serbo-Turkish war of 1876[7] even though the wagons were first referred to as ambulances about 1854 during the Crimean War.[8]
History
The history of the ambulance begins in ancient times, with the use of carts to transport incurable patients by force. Ambulances were first used for emergency transport in 1487 by the Spanish, and civilian variants were put into operation during the 1830s.[9] Advances in technology throughout the 19th and 20th centuries led to modern self-powered ambulances.
Functional types
Ambulances can be grouped into types depending on whether or not they transport patients, and under what conditions. In some cases, ambulances may fulfill more than one function (such as combining emergency ambulance care with patient transport:
- Emergency ambulance – The most common type of ambulance, which provides care to patients with an acute illness or injury. These can be road-going vans, boats, helicopters, fixed-wing aircraft (known as air ambulances), or even converted vehicles such as golf carts.
- Patient transport ambulance – A vehicle, which has the job of transporting patients to, from or between places of medical treatment, such as hospital or dialysis center, for non-urgent care. These can be vans, buses, or other vehicles.
- Ambulance bus – A large ambulance, usually based on a bus chassis, that can evacuate and transport a large number of patients. They are usually used in emergencies such as mass casualty incidents.
- Charity ambulance – A special type of patient transport ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices, or care homes where they are in long-term care. Examples include the United Kingdom's "Jumbulance" project.[10] These are usually based on a bus.
- Bariatric ambulance – A special type of patient transport ambulance designed for extremely obese patients equipped with the appropriate tools to move and manage these patients.
- Rapid organ recovery ambulance – A special ambulance used to collect the bodies of people who have died to preserve their organs.[11][12] In 2008, New York City launched a pilot program deploying one such ambulance with a $1.5 million three-year grant.[11]
- Psychiatric ambulance – A special ambulance dedicated to treat psychiatric emergencies. The idea was first tested as "Psykebilen" ("The Psych ambo") in Bergen, Norway in 2005, and was soon adopted by other cities in Norway and Sweden. Tests from the time showed that an ambulance service with personnel specially trained in psychiatric treatment was highly effective, and reduced the use of force when treating patients in psychiatric crises.[13][14]
Vehicle types
Ambulances can be based on many types of vehicle although emergency and disaster conditions may lead to other vehicles serving as makeshift ambulances:
- Van or pickup truck – A typical general-purpose ambulance is based on either the chassis of a van ("vanbulance") or a light-duty truck. This chassis is then modified to the designs and specifications of the purchaser. Vans may either retain their original body and be upfitted inside, or may be based on a chassis without the original body with a modular box body fitted instead. Those based on pickup trucks almost always have modular bodies. Those vehicles intended for especially intensive care or require a large amount of equipment to be carried may be based on medium-duty trucks.
- Car – Used either as a fly-car for rapid response[2] or to transport patients who can sit, these are standard car models adapted to the requirements of the service using them. Some cars are capable of taking a stretcher with a recumbent patient, but this often requires the removal of the front passenger seat, or the use of a particularly long car. This was often the case with early ambulances, which were converted (or even serving) hearses, as these were some of the few vehicles able to accept a human body in a supine position. Some operators use modular-body transport ambulances based on the chassis of a minivan or station wagon.
- Motorcycle and motor scooter – In urban areas, these may be used for rapid response in an emergency[15] as they can travel through heavy traffic much faster than a car or van. Trailers or sidecars can make these patient transporting units.[16][17]
- Bicycle – Used for response, but usually in pedestrian-only areas where large vehicles find access difficult.[18][19] Like the motorcycle ambulance, a bicycle may be connected to a trailer for patient transport, most often in the developing world.[20]
- All-terrain vehicle – Used for response off-road,[21] especially at events or in remote areas. ATVs can be modified to carry a stretcher, and are used for tasks such as mountain rescue in inaccessible areas.
- Golf cart or Neighborhood Electric Vehicle – Used for rapid response at events[22] or on campuses. These function similarly to ATVs, with less rough terrain capability, but with less noise.
- Bus – In some cases, buses can be used for multiple casualty transport, either for the purposes of taking patients on journeys,[10] in the context of major incidents, or to deal with specific problems such as drunken patients in town centers.[23][24] Ambulance buses are discussed at greater length in their own article.
- air ambulance.
- air ambulance.
- Boat – Boats can be used to serve as water ambulances, especially in island areas[28] or in areas with a large number of canals. Some lifeboats or lifeguard vessels may fit the description of an ambulance as they are used to transport a casualty.
- Train – In remote or hard-to-reach areas that are accessed primarily by railway connections, trains may be used to provide medical care as a mobile treatment facility or transport patients to better care in more accessible areas. These are generally called hospital trains.
- Trailer – In some instances, a trailer, which can be towed behind a self-propelled vehicle, can be used as an ambulance. This permits flexibility in areas with minimal access to vehicles, such as on small islands.[29]
- Horse and cart – Especially in the developing world, more traditional methods of transport include horse and cart, used in much the same way as motorcycle or bicycle stretcher units to transport to a local clinic.
- Fire engine – Fire services (especially in North America) often train firefighters to respond to medical emergencies and most apparatuses carry at least basic medical supplies. By design, most apparatuses cannot transport patients unless they can sit in the cab. However, some fire trucks may be designed to have a large ambulance compartment behind the front of the cab, where the driver and officer's seats are located.
Vehicle type gallery
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A Navistar truck ambulance operated by the District of Columbia Fire and Emergency Medical Services Department
-
A paramedic bicycle operated by the London Ambulance Service
-
An all-terrain vehicle ambulance with a trailer operated by the Pol'and'Rock Festival's Medical Patrol
-
AFeuerwehr
-
Aair ambulance operated by Rega
-
A Pilatus PC-12 plane air ambulance operated by the Royal Flying Doctor Service
-
A water ambulance operated by the Norwegian Society for Sea Rescue
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A Pierce Quantum operated by Las Vegas Fire & Rescue; note the "PARAMEDIC" text near the rear wheel
Design and construction
Ambulance design must take into account local conditions and infrastructure. Maintained roads are necessary for road-going ambulances to arrive on scene and then transport the patient to a hospital, though in rugged areas four-wheel drive or all-terrain vehicles can be used. Fuel must be available and service facilities are necessary to maintain the vehicle.
Methods of summoning (e.g. telephone) and
Ambulances often have two stages of manufacturing. The first is frequently the manufacture of light or medium truck chassis-cabs or full-size vans (or in some places, cars) such as
Modern ambulances are typically powered by internal combustion engines, which can be powered by any conventional fuel, including diesel, gasoline or liquefied petroleum gas,[33][34] depending on the preference of the operator and the availability of different options. Colder regions often use gasoline-powered engines, as diesels can be difficult to start when they are cold. Warmer regions may favor diesel engines, as they are more efficient and more durable. Diesel power is sometimes chosen due to safety concerns, after a series of fires involving gasoline-powered ambulances during the 1980s. These fires were ultimately attributed in part to gasoline's higher volatility in comparison to diesel fuel.[35][36] The type of engine may be determined by the manufacturer: in the past two decades, Ford[37][38][39] would only sell vehicles for ambulance conversion if they are diesel-powered. Beginning in 2010, Ford will sell its ambulance chassis with a gasoline engine in order to meet emissions requirements.[40]
Standards
Many regions have prescribed standards which ambulances should, or must, meet in order to be used for their role. These standards may have different levels which reflect the type of patient which the ambulance is expected to transport (for instance specifying a different standard for routine patient transport than high dependency), or may base standards on the size of vehicle.
For instance, in Europe, the European Committee for Standardization publishes the standard CEN 1789, which specifies minimum compliance levels across the build of ambulance, including crash resistance, equipment levels, and exterior marking. In the United States, standards for ambulance design have existed since 1976, where the standard is published by the General Services Administration and known as KKK-A-1822.[41] This standard has been revised several times, and is currently in version 'F' change notice #13, known as KKK-A-1822F. The National Fire Protection Association has also published a design standard, NFPA 1917, which offers an alternative to KKK-A-1822F.[42] The Commission on Accreditation of Ambulance Services (CAAS) has published its Ground Vehicle Standard for Ambulances v2.0, effective July 2019. This standard is similar to the KKK-A-1822F and NFPA 1917–2019 specifications. The decision on which of the current (3) standards to require is left up to each individual state legislature or EMS director. Some states have no specific requirement, while others specify which standard is acceptable. Others, yet, allow the end user to decide which standard to comply to.
In the United States and Canada, there are four types of ambulances: Type I, Type II, Type III, and Type IV. Type I is based on a
The move towards standardisation is now reaching countries without a history of prescriptive codes, such as India, which approved its first national standard for ambulance construction in 2013.[46]
Safety
Ambulances, like other
Equipment
In addition to the equipment directly used for the treatment of patients, ambulances may be fitted with a range of additional equipment which is used in order to facilitate patient care. This could include:
- Two-way radio – One of the most important pieces of equipment in modern emergency medical services as it allows for the issuing of jobs to the ambulance, and can allow the crew to pass information back to control or to the hospital (for example a priority TETRA.[51]
- Mobile data terminal – Some ambulances are fitted with mobile data terminals (or MDTs), which are connected wirelessly to a central computer, usually at the control center. These terminals can function instead of or alongside the two-way radio and can be used to pass details of jobs to the crew, and can log the time the crew was mobile to a patient, arrived, and left the scene, or fulfill any other computer-based function.[52]
- Evidence gathering CCTV – Some ambulances are now being fitted with video cameras used to record activity either inside or outside the vehicle. They may also be fitted with sound recording facilities. This can be used as a form of protection from violence against ambulance crews,[53] or in some cases (dependent on local laws) to prove or disprove cases where a member of the crew stands accused of malpractice.
- neonatal incubator or hospital beds. There may also be equipment linked to this such as winches which are designed to pull heavy patients into the vehicle.[54]
- Trauma lighting – In addition to normal working lighting, ambulances can be fitted with special lighting (often blue or red) which is used when the patient becomes photosensitive.
- filteringagainst airborne pathogens.
- Data recorders – These are often placed in ambulances to record such information as speed, braking power and time, activation of active emergency warnings such as lights and sirens, as well as seat belt usage. These are often used in coordination with GPS units.[55]
Intermediate technology
In parts of the world that lack a high level of infrastructure, ambulances are designed to meet local conditions, being built using
The design of intermediate technology ambulances must take into account not only the operation and maintenance of the ambulance, but its construction as well. The robustness of the design becomes more important, as does the nature of the skills required to properly operate the vehicle. Cost-effectiveness can be a high priority.[17][56]
Appearance and markings
Emergency ambulances are highly likely to be involved in hazardous situations, including incidents such as a
Passive visual warnings
Passive visual warnings are usually part of the design of the vehicle, and involve the use of high contrast patterns. Older ambulances (and those in
Another passive marking form is the word ambulance (or local language variant) spelled out in reverse on the front of the vehicle. This enables drivers of other vehicles to more easily identify an approaching ambulance in their
Ambulances may also carry an emblem (either as part of the passive warning markings or not), such as a Red Cross, Red Crescent or Red Crystal (collective known as the
The Star of Life is widely used, and was originally designed and governed by the U.S. National Highway Traffic Safety Administration,[61] because the Red Cross symbol is legally protected by both National[62] and international[63][64] law.
Ambulance services with historical origins such as the
Active visual warnings
The active visual warnings are usually in the form of flashing lights. These flash in order to attract the attention of other road users as the ambulance approaches, or to provide warning to motorists approaching a stopped ambulance in a dangerous position on the road. Common colours for ambulance warning beacons are blue, red, amber, and white (clear). However the colours may vary by country and sometimes by operator.[citation needed]
There are several technologies in use to achieve the flashing effect. These include flashing a
Emergency lights may simply be mounted directly on the body, or may be housed in special fittings, such as in a
In order to increase safety, it is best practice to have 360° coverage with the active warnings, improving the chance of the vehicle being seen from all sides. In some countries, such as the United States, this may be mandatory. The roof, front grille, sides and rear of the body, and front fenders are common places to mount emergency lights. A certain balance must be made when deciding on the number and location of lights: too few and the ambulance may not be noticed easily, too many and it becomes a massive distraction for other road users more than it is already, increasing the risk of local accidents.[citation needed]
Audible warnings
In addition to visual warnings, ambulances can be fitted with audible warnings, sometimes known as
The speakers for modern sirens can be integral to the lightbar, or they may be hidden in or flush to the grill to reduce noise inside the ambulance that may interfere with patient care and radio communications. Ambulances can additionally be fitted with
A recent[
Costs
The cost of an ambulance ride may be paid for from several sources, and this will depend on the local situation type of service being provided, by whom, and to whom.
- Government-funded service – The full or the majority of the cost of transport by ambulance is borne by the local, regional, or national government (through their normal taxation).[74]
- Privately-funded service – Transport by ambulance is paid for by the patient themselves, or through their insurance company. This may be at the point of care (i.e. payment or guarantee must be made before treatment or transport), although this may be an issue with critically injured patients, unable to provide such details, or via a system of billing later on.[75]
- Charity-funded service – Transport by ambulance may be provided free of charge to patients by a charity, although donations may be sought for services received.[76]
- Hospital-funded service – Hospitals may provide the ambulance transport free of charge, on the condition that patients use the hospital's services (which they may have to pay for).[77]
Crewing
There are differing levels of qualification that the ambulance crew may hold, from holding no formal qualification to having a fully qualified doctor on board. Most ambulance services require at least two crew members to be on every ambulance (one to drive, and one to attend the patient). It may be the case that only the attendant need be qualified, and the driver might have no medical training. In some locations, an advanced life support ambulance may be crewed by one paramedic and one technician, or in countries like Australia advanced life support registered paramedics.
Common ambulance crew qualifications are:
- First responder – A person who arrives first at the scene of an incident,[78] and whose job is to provide early critical care such as cardiopulmonary resuscitation (CPR) or using an automated external defibrillator (AED). First responders may be dispatched by the ambulance service, may be passers-by, or may be dispatched to the scene from other agencies, such as the police or fire departments. They may be on duty for another agency, or volunteers who are on-call during their free time.
- Ambulance driver – Some services employ staff with no medical qualification (or just basic first aid training) whose job is to simply drive the vehicle. In some emergency ambulance contexts this term is a pejorative towards personnel with higher medical training, as it implies they perform no function other than driving, although it may be acceptable for patient transport or community operations. Ambulance drivers may also have training in using the radio and knowing where medical supplies are stored in the ambulance.
- Non-emergency attendant – This role has different levels of training across the world, but these staff are usually only required to perform patient transport duties (which can include stretcher or palliativeskills. They may provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.
- Emergency care assistant – Members of a frontline ambulance that drive the vehicles under both emergency and non-emergency conditions to incidents. Their role is to assist the clinician that they are working with, either a Technician or Paramedic, in their duties, whether that be drawing up drugs, setting up fluids (but not attaching), doing basic observations or performing 12 lead ECG assessments.
- EMT-Intermediate).[80]
- Registered nurse – In some systems, nurses are the primary providers of advanced-level care on ambulances, often in place of paramedics. This includes Estonia, the Netherlands,[81] Sweden[82] and Spain.[83] Nurses may also work on ambulances for critical care transport.
- Paramedic – This is a high level of medical training and usually involves key skills not permissible for technicians, such as cannulation (and with it the ability to administer a range of drugs such as morphine), tracheal intubation and other skills such as performing a cricothyrotomy.[84] Dependent on jurisdiction, the title "paramedic" can be a protected title, and use of it without the relevant qualification may result in criminal prosecution.[85]
- Emergency care practitioner – This position is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are already qualified paramedics who have undergone further training,[86]and are trained to prescribe medicines for longer-term care, such as antibiotics, as well as being trained in a range of additional diagnostic techniques.
- Physician assistant – Physician Assistants are found predominately in English-speaking countries and may also be known as physician associates in some countries. PA's mirror the practice of a physician and are capable of providing the range of medical skills a physician provides. They generally work in collaboration with a physician, although in an ambulance environment this may not be possible. Instead, advanced directives or electronic communication is available to PA's to consult with physicians when required.
- Physician – In some systems such as the SAMU in France, it is common for doctors to staff ambulances. On the other hand, this is rare in systems that rely heavily on paramedics or field nurses. In those cases, doctors may be present in specialist ambulance units – most notably the air ambulances. Alternatively, in some systems, such as Albuquerque, NM and Pittsburgh, PA, physicians are available to respond to serious cases via a fly car.[87][88][89]
Military use
Military ambulances have historically included vehicles based on civilian designs and at times also included armored, but unarmed, vehicle ambulances based upon
Since
The
Some navies operate ocean-going
Ambulette
Ambulettes provide patient transport service for non-emergency situations. Scheduling is a major factor in their effective use.[101]
Reuse of retired ambulances
When an ambulance is retired, it may be donated or sold to another EMS provider.[102][103] Alternately, it may be adapted into a storage and transport vehicle for crime scene identification equipment, a command post at community events, or support vehicle, such as a logistics unit.[104] Others are refurbished and resold,[105] or may just have their emergency equipment removed to be sold to private businesses or individuals, who then can use them as small recreational vehicles. They may also have a perfectly serviceable body or vehicle (or both) separated from the other and reused.
Toronto City Council operates a "Caravan of Hope" project to give retired Toronto ambulances a second life by donating them to the people of El Salvador. Since Ontario laws require ambulances to be retired after just four and a half years in service, the City of Toronto decommissions and auctions around 28 ambulances each year.[106]
See also
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External links
- Quotations related to Ambulance at Wikiquote
- Media related to Ambulances at Wikimedia Commons