An ambulance is a vehicle for transporting sick or injured people, to, from or between places of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to bring medical care to patients outside of the hospital or to transport the patient to hospital for follow-up care and further testing. In some jurisdictions there is a modified form of the ambulance used, that only carries one member of ambulance crew to the scene to provide care, but is not used to transport the patient. In these cases a patient who requires transportation to hospital will require a patient-carrying ambulance to attend in addition to the fast responder.
The term ambulance comes from the Latin word ambulare, meaning to walk or move about 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. During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons. Field hospitals were still called ambulances during the Franco-Prussian War of 1870 and in the Serbo-Turkish war of 1876 even though the wagons were first referred to as ambulances about 1854 during the Crimean War.
Nowadays the word is most commonly associated with the land-based, emergency motor vehicles that administer emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with flashing warning lights and sirens to facilitate their movement through traffic. It is these emergency ambulances that are most likely to display the Star of Life, which represents the six stages of prehospital medical care.
There are other types of ambulance, with the most common being the patient transport 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. Their purpose is simply to transport patients to, from or between places of treatment. In most countries, these are not equipped with flashing lights or sirens.
During the Crusades of the 11th century, the Knights of St John set up hospitals to treat pilgrims wounded in their battles in the 'holy land', although there is no clear evidence to suggest how the wounded made their way to these hospitals.
A major change in usage of ambulances in battle came about with the ambulance volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte’s chief physician. Larrey was present at the battle of Spires, between the French and Prussians, 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 has 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 drawn wagons were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. These 'flying ambulances' were first used by Napoleons Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon's other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt.
In 1867, the city of London's Metropolitan Asylums Board, in the United Kingdom, received six horse-drawn ambulances for the purpose of conveying smallpox and fever patients from their homes to a hospital. These ambulances were designed to resemble private carriages, but were equipped with rollers in their floors and large rear doors to allow for a patient, lying on a specially designed bed, to be easily loaded. Space was provided for an attendant to ride with the patient, and the entire patient compartment was designed to be easily cleaned and decontaminated. Anyone willing to pay the cost of horse hire could summon the ambulance by telegram or in person.
In Ireland the St John Ambulance was set up in 1903 in the Guinness Brewery in St. James Gate in Dublin by Doctor, later Sir, John Lumsden for workers. In 1910 the Brigade began its first public duty at the Royal Dublin Society. During the 1916 rising and (after becoming the independent St John Ambulance Brigade of Ireland) the 'Emergency' (World War II) the brigade acted as an ambulance service and remained so until the set up of Regional Ambulance Services.
In Queensland, a state in Australia, military medic Seymour Warrian called a public meeting in Brisbane and established an ambulance service after witnessing an event at the Brisbane showgrounds during Show Week in 1892. A fallen rider, suffering a broken leg was walked off the field by well meaning but misguided bystanders, worsening his injury. As a result of the meeting, the Queensland Ambulance Transport Brigade was formed on the 12 September. The first ambulance station in Queensland operated out of the Brisbane Newspaper Company and officers on night duty slept on rolls of newspaper on the floor. They had a stretcher, but no vehicle and transported patients on foot, although in time, they gained horse drawn stretchers and eventually vehicles. A year after the establishment of the Brisbane centre, another was established in Charters Towers in north Queensland, growing to over 90 community controlled ambulance centres. In 1991 the independent QATB centres amalgamated to form the Queensland Ambulance Service which is now the fourth largest ambulance service in the world.
In Germany, in 1902, a civilian ambulance train was introduced (building on the use of trains during military conflict) for use during railway accidents. It housed a mobile operating room and eight stretchers. Railroad employed surgeons lived near the railway station where the ambulance train was stationed, and were summoned to urgently attend in the event of an emergency. The train had priority over the tracks, with all other trains obliged to give way.
In the late 19th century, the automobile was being developed, and started to be introduced alongside horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motor powered ambulance was brought in to service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, 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 motors on the rear axle.
The first gasoline powered ambulance was the Palliser Ambulance, introduced in 1905, and named for Major Palliser of the Canadian Militia. This three wheeled vehicle (one at the front, two at the rear) was designed for use on the battlefield, under enemy fire. It was a heavy tractor unit, cased in bullet proof steel sheets. These steel shields opened outwards to provide a small area of cover from fire (nine feet wide by high) for the ambulance staff when the vehicle was stationary.
The British Army was quickly behind the Canadians in introducing a limited number of automobile ambulances. In 1905, the Royal Army Medical Corps commissioned a number of Straker-Squire motor ambulance vans. They were based on a double decker bus manufactured by the same company, although on a shorter wheel base. A number of them were based in Oxfordshire, serving several major encampments in the area.
The first mass production automobile based ambulance (rather than one off models) was produced in the United States by the James Cunningham, Son & Company of Rochester, New York, a manufacturer of carriages and hearses, in 1909. This ambulance was named the Model 774 Automobile Ambulance. The ambulance featured a proprietary , 4 cylinder internal combustion engine. The chassis rode on pneumatic tires, while the body featured electric lights, a suspended cot with two attendant seats, and a side mounted gong.
During World War One, the Red Cross brought in the first widespread battlefield motor ambulances to replace horse drawn vehicles, which was such a success, the horse drawn variants were quickly phased out. In civilian emergency care, dedicated ambulance services were frequently managed or dispatched by individual hospitals, though in some areas, telegraph and telephone services enabled police departments to handle dispatch duties.
The equipment carried by the ambulance was changing fast at this time. Traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. It was frequently found that ambulances were hearses – the only available vehicle that could carry a recumbent patient – and were thus frequently run by funeral homes, these vehicles which could serve for either purpose were known as combination cars.
During World War One, aviation moved from experimentation to a powerful military force, and following the war, with a surplus of aircraft in circulation, new uses were found for the aircraft. This included the conversion of planes throughout the world in to ambulance planes. Although in 1917, Lieutenant Clifford Peel, a medical student, outlined a system of fixed-wing aircraft and ground facilities designed to provide medical services to the Australian Outback, the first custom built air ambulances did not come in to existence until the late 1920s. These ideas became reality under the guidance of the Very Reverend John Flynn in 1928 when the Australian Inland Mission service established the Aerial Medical Service, a one year experimental program. Physicians in this program had several responsibilities, one of which was to fly out to a patient, treat the patient, and fly the patient to a hospital if the physician could not deliver adequate care on scene. Eventually, this experiment became the Royal Flying Doctor Service of Australia.
In much of the world, ambulance quality fell sharply during the second world war, as physicians, needed by the armed services, were pulled off of ambulances. In England, during the Battle of Britain, the need for ambulances was so great that vans were commandeered and pressed into service, often carrying several victims at once. Following the war, physicians would continue to ride ambulances in some countries, but not in others. Other vehicles, including civilian and police cars were pressed in to service to transport patients due to a lack of a dedicated resource. Military ambulances such as the Austin K2 were used both in the combat areas and on the Home Front
After the Harrow and Wealdstone rail crash, ambulances were restructured to be a "mobile hospital", rather than just transporting patients, thus leading to modern ambulances. CPR was developed and accepted as the standard of care for out-of-hospital cardiac arrest; defibrillation, based in part on an increased understanding of heart arrhythmias, was introduced, as were new pharmaceuticals to be used in cardiac arrest situations; in Ireland, a mobile coronary care ambulance successfully resuscitated patients using these technologies; and well-developed studies demonstrated the need for overhauling ambulance services. These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), in the equipment (and thus weight) that an ambulance had to carry. Few, or perhaps none of the then-available ambulances could meet these standards.
Most ambulances at the time, were built on a car chassis (often based on hearses), which could not accept the weight and other demands of the new standards; van (and later, light truck) chassis would have to be used instead.
Ambulance design therefore underwent major changes in the 1970s. The early van-based ambulances looked very similar to their civilian counterparts, having been given a limited amount of emergency vehicle equipment such as audible and visual warnings, and the internal fittings for carrying medical equipment, most notably a stretcher.
As time went on, ambulances matured in parallel to the newly developed EMS, gaining the capacity to carry additional equipment (both portable and permanently installed) as EMTs and paramedics added this equipment to their arsenal. .
Modern ambulances are now often custom built (see Design and construction below), and as well as the specialist medical equipment now built in to the ambulances, industry wide improvements in vehicle design have had an impact, including improvements in audible and visual warning equipment to help protect crews in vulnerable situations (such as at a Road Traffic Collision), and general improvements such as ABS, which are particularly valuable for ambulances, due to the speeds reached and the weight carried. There have also been improvements to help safeguard the health and welfare of ambulance crews, such as the addition of patient tail lifts, ramps and winches, to cut down on the amount of manual handling a crew must perform.
Ambulance design is still evolving, largely due to the growing skills and role of Paramedics and other ambulance crew, which require specialist equipment. Other factors driving improvement include the need to help protect ambulance crews from common accidents, such as traffic collisions and rarer, but potentially catastrophic incidents such as terrorist activities.
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 dispatching ambulances usually rely on electronic equipment, which itself often relies on an intact power grid. Similarly, modern ambulances are equipped with two-way radios or cellular telephones to enable them to contact hospitals, either to notify the appropriate hospital of the ambulance's pending arrival, or, in cases where physicians do not form part of the ambulance's crew, to confer with a physician for medical oversight.
Ambulances often have two manufacturers. The first is frequently a manufacturer of light trucks (or previously, cars) such as Mercedes-Benz or Ford. The second manufacturer purchases the vehicle (which is sometimes purchased incomplete, having no body or interior behind the driver's seat) and turns it into an ambulance by adding bodywork, emergency vehicle equipment, and interior fittings. This is done by one of two methods – either coachbuilding, where the modifications are started from scratch and built on to the vehicle, or using a modular system, where a pre-built 'box' is put on to the empty chassis of the ambulance, and then finished off.
Modern ambulances are typically powered by internal combustion engines, which can be powered by any conventional fuel, including diesel, gasoline or liquefied petroleum gas, 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 thought to be 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. The type of engine may be determined by the manufacturer: Ford will only sell vehicles for ambulance conversion if they are diesel powered.
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.
Emergency ambulances are highly likely to be involved in hazardous situations, including incidents such as a road traffic collision, as these emergencies create people who are likely to be in need of treatment. They are required to gain access to patients as quickly as possible, and in many countries, are given dispensation from obeying certain traffic laws (for instance, they may be able to treat a red traffic light or stop sign as a yield ('give way') sign, or be permitted to break the speed limit).
For these reasons, emergency ambulances are often fitted with visual and/or audible warnings to alert road users.
Visual warnings on an ambulance can be of two types – either passive or active.
The 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 developing countries) are more likely to have their pattern painted on, whereas modern ambulances generally carry retro-reflective designs which reflect light from car headlights or torches. Popular patterns include 'checker board' (alternate coloured squares, sometimes called 'Battenburg', named after a type of cake), chevrons (arrowheads – often pointed towards the front of the vehicle if on the side, or pointing vertically upwards on the rear) or stripes along the side (these were the first type or retro-reflective device introduced, as the original reflective material, invented by 3M, only came in tape form). In addition to retro-reflective markings, some services now have the vehicles painted in a bright (sometimes fluorescent) yellow or orange for maximum visual impact. In Europe this colour is defined as Euro Yellow RAL 1016 for emergency service vehicles.
Another passive marking form is the word ambulance 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 rear view mirrors. Ambulances may display the name of their owner or operator, and a telephone number which may be used to summon the ambulance.
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 Protective Symbols). These are symbols laid down by the Geneva Convention, and all countries signatory to it agree to restrict their use to either (1) Military Ambulances or (2) the national Red Cross or Red Crescent society. Use by any other person, organization or agency is in breach of international law. The protective symbols are designed to indicate to all people (especially combatants in the case of war) that the vehicle is neutral and is not to be fired upon (more detail below in “military ambulances”), hence giving protection to the medics and their casualties, although this has not always been adhered to. In Israel, Magen David Adom, the Red Cross member organization use a Red Star of David, but this does not have recognition beyond Israeli borders, where they must use the Red Crystal.
The Star of Life is widely used, and was originally designed and governed by the U.S. National Highway Traffic Safety Administration, after legal action by the Red Cross over alleged misuse of their symbol (by using a bright orange cross, felt to be too similar to the Red Cross device). It indicates that the vehicle's operators can render their given level of care represented on the six pointed star. Ambulance services that have historical origins in the Order of St John often use the Maltese cross to identify their ambulances. This is especially important in countries such as Australia, where St John Ambulance operate one state and one territory ambulance service, and all of Australia's other ambulance services use variations on a red Maltese cross.
Fire service operated ambulances may display the Cross of St. Florian (often, incorrectly, called a Maltese cross) as this cross is frequently used as a fire department logo (St Florian being the patron saint of firefighters).
The active visual warnings are usually in the form of flashing coloured lights (sometimes known as 'beacons' or 'lightbars'). 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 and red, and this varies by country (and sometimes by operator).
There are several different technologies in use to achieve the flashing effect. The original method of producing flashing was to place a spinning mirror which moves around a light bulb, called a 'rotating beacon'. More modern methods include the use of strobe lights, which are usually brighter, and can be programmed to produce specific patterns (such as a left -> right pattern when parked on the left hand side of the road, indicating to other road users that they should move out away from the vehicle). There is currently the more widespread use of LED flashing lights as they are low profile and low energy. More information on Emergency vehicle equipment.
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 obligatory.
In addition to visual warnings, ambulances can be fitted with audible warnings, sometimes known as sirens, which can alert people and vehicles to the presence of an ambulance before they can be seen. The first audible warnings were mechanical bells, mounted to either the front or roof of the ambulance. Most modern ambulances are now fitted with electronic sirens, which can produce a range of different noises.
Ambulance services may specifically train their drivers to use different siren tones in different driving situations. For instance, on a clear road the 'wail' setting may be used, which gives a long and steady up and down variation. At busy intersections, the a 'yelp' setting may be employed, which delivers a more rapid bursting signal. 'Dual tone' and 'phaser' modes are also available on many modern sirens. Changing the speed and pitch of the warning intensifies the alert delivered to drivers in the ambulance's path.
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 airhorn audible warnings to augment the effectiveness of the siren system.
A recent development is the use of the RDS system of car radios. The ambulance is fitted with a short range FM transmitter, set to RDS code 31, which interrupts the radio of all cars within range, in the manner of a traffic broadcast, but in such a way that the user of the receiving radio is unable to opt out of the message (as with traffic broadcasts). This feature is built in to every RDS radio for use in national emergency broadcast systems, but short range units on emergency vehicles can prove an effective means of alerting traffic to their presence. It is, however, unlikely that this system could replace audible warnings, as it is unable to alert pedestrians, or those not using a compatible radio.
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.
Common ambulance crew qualifications are:
Military ambulances include both ambulances based on civilian designs and armored but unarmed ambulances based upon APCs such as the FV104 Samaritan. Civilian based designs may be painted in olive, white or other colours, depending on the operational requirements – the British Royal Army Medical Corps has a fleet of white ambulances, based on production trucks. Military helicopters often function as air ambulances, since they are extremely useful for MEDEVAC.
Due to the inherently hazardous situation of a battle ground, Military ambulances are often armored, or based upon armored fighting vehicles (AFV). Since laws of war demand ambulances marked with one of the Emblems of the Red Cross not to mount weapons, an ambulance AFV is unarmed. It is a generally accepted practice in most countries to classify the personnel attached to military vehicles marked as ambulances as non-combatants; however, this application does not always exempt medical personnel from enemy fire —accidental or deliberate. As a result, medics and other medical personnel attached to military ambulances are usually put through basic military training, on the assumption that they may have to use a weapon. The laws of war allow non-combatant military personnel to carry individual weapons for protecting themselves and casualties, but not all militaries exercise this right.
Recently, Israel has modified a number of its Merkava main battle tanks with ambulance features in order to allow rescue operations to take place under heavy fire in urban warfare. The modifications were made following a failed rescue attempt in which Palestinian gunmen killed two soldiers who aided a Palestinian woman in Rafah. Since M-113 armored personnel carriers and regular up-armored ambulances are not sufficiently protected against anti-tank weapons and improvised explosive devices, it was decided to use the heavily armored Merkava tank. Its rear door enables the evacuation of critically wounded soldiers. Israel did not remove the Merkava's weaponry, claiming that weapons were more effective protection than emblems since Palestinian militants would disregard any symbols of protection and fire at ambulances anyway.
Some navies operate ocean-going hospital ships to lend medical assistance in high casualty situations like wars or natural disasters. These hospital ships fulfil the criteria of an ambulance (transporting the sick or injured), although the capabilities of a hospital ship are more on par with a Mobile Army Surgical Hospital. In line with the laws of war, these ships can display a prominent Red Cross or Red Crescent to infer protection under the appropriate Geneva convention, however, this designation has not always protected hospital ships from enemy fire.