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Ambulance

[am-byuh-luhns]

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.

Other vehicles used as ambulances include trucks, vans, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships.

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 fulfil more than one function (such as combining emergency ambulance care with patient transport).

Emergency ambulance – The most common type of ambulance, which provide 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.
Response unit – Also known as a fly-car, which is a vehicle which is used to reach an acutely ill patient quickly, and provide on scene care, but lacks the capacity to transport the patient from the scene. Response units may be backed up by an emergency ambulance which can transport the patient, or may deal with the problem on scene, with no requirement for a transport ambulance. These can be a wide variety of vehicles, from standard cars, to modified vans, motorcycles, pedal cycles, quad bikes or horses. These units can function as a vehicle for officers or supervisors (similar to a fire chief's vehicle, but for ambulance services).
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. These are usually based on a bus.

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 – A typical ambulance is of a van construction, based on a standard chassis, usually with a maximum road weight loaded of between 3.5 and 7.5 tonnes. In North America, the large box type vehicles are referred to as "mods" (modular) and the smaller van type vehicle is often called a "high-top".
Car/SUV – Used either as a fly-car for rapid response or for 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).
Motorcycle – In developed areas, these are used for rapid response in an emergency as they can travel through heavy traffic much faster than a car or van, although in the developing world, trailer or sidecar adaptations make these patient transporting units.
Bicycle – Used for response, but usually in pedestrian only areas where large vehicles find access difficult. Like the motorcycle, a bicycle may be connected to a trailer for patient transport, most often in the developing world.
All Terrain Vehicle – for example quad bikes; these are used for response off road, especially at events. ATVs can be modified to carry a stretcher, and are used for tasks such as mountain rescue in inaccessible areas.
Golf cart – Used for rapid response at events. These function similarly to ATVs, with less rough terrain capability, but with less noise.
Helicopter – Usually used for emergency care, either in places inaccessible by road, or in areas where speed is of the essence, as they are able to travel significantly faster than a road ambulance.
Fixed-wing aircraft – These can be used for either acute emergency care in remote areas (such as in Australia, with the 'Flying Doctors') or for patient transport over long distances (usually a re-patriation following an illness or injury in a foreign country).
Boat – Boats can be used to serve as ambulances, especially in island areas or in areas with a large number of canals, such as the Venetian boat ambulances. Some lifeboats or lifeguard vessels may fit the description of an ambulance as they are used to transport a casualty.
Ship – Ships can be used as hospital ships, mostly operated by national military services, although some ships are operated by charities. They can meet the definition of ambulances as they provide transport to the sick and wounded (along with treatment). They are often sent to disaster or war zones to provide care for the casualties of these events.

History

Early patient transport

There is evidence of forced transport of those with psychiatric problems or leprosy in to ancient times. The first record of an ambulance was probably a hammock based cart constructed around 900 AD by the Anglo-Saxons.

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.

In Norman times, a litter suspended between horses on two poles was used. Variations on the horse litter and horse-drawn wagons were used from then right up to the 20th century.

Early battlefield treatment

The first record of ambulances being used for emergency purposes was the use by Queen Isabella of Spain, in 1487. The Spanish army of the time was treated extremely well and attracted volunteers from across the continent, and part of this was the first military hospitals or 'ambulancias', although injured soldiers were not picked up for treatment until after the cessation of the battle, resulting in many dying on the field.

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.

Development of civilian services

In civilian ambulances, a major advance was made with the introduction of a transport carriage for cholera patients in London in 1832. The Times newspaper said that "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".

Advances during the American Civil War

More advances in medical care for the military were made during the United States’ Civil War. Union military physicians Joseph Barnes and Jonathan Letterman built upon Larrey’s work and designed a prehospital care system for soldiers, which used new techniques and methods of transport. They ensured that every regiment possessed at least one ambulance cart, with a two wheel design that accommodated two or three patients. These ambulances unfortunately proved to be too lightweight for the task, and were phased out to be replaced by the "Rucker" ambulance, named for Major General Rucker, which was a four wheeled design, and was a common sight on battlefield of that war. Other vehicles were pressed in to service during the civil war, including a number of Steamboats, which served as mobile hospitals for the troops. It was in this period that the practice of transporting wounded soldiers to treatment facilities by railroad was introduced.

Hospital based services begin

The first known hospital based ambulance service was based out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service provided out of Bellevue Hospital. Edward Dalton, a former surgeon in the Union Army, was charged with creating a hospital in lower New York, he started an ambulance service to bring the patients to the hospital faster and in more comfort, which started in 1869. He claimed the service was the first of its kind, being unaware of the work in Cincinnati four year earlier. These ambulances carried medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. Dalton believed that speed was of the essence, and horses were left harnessed, being attached to the ambulance by a 'drop' or 'snap' harness, meaning they were ready to go within 30 seconds of being called. The service was very popular and grew rapidly, with the year 1870 seeing the ambulances attend 1401 emergency calls, but twenty one years later, this had more than tripled to 4392. By the turn of the century, interns accompanied New York City ambulances, treated patients on scene, and often left them at home.

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.

Dedicated services begin

In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modeled on a military-style command and discipline structure. The St John Ambulance Association had already been teaching first aid to the public for 10 years prior to that. National or state based branches of St John Ambulance now provides ambulance and first aid services in many countries around the world.

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.

Mass transit use for emergency medical provision

In the late 19th century cities, including Bahia, Brazil and St Louis, Missouri, United States started using trolley cars on their tram network which were designed to act as ambulances, transporting the sick and injured. The trolley cars in Bahia included a fumigating compartment and a two bed nurses work area. The design of the tram network in St Louis was such that the ambulance streetcar, introduced in 1894 was able to reach all 16 infirmaries in the city.

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.

Introduction of motor units

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.

World War I

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.

Air ambulances

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.

World War II

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

The Korean War

During the Korean War, the newly created United States Air Force created a number of air ambulance units for use in forward operating medical units, using helicopters for rapid evacuation of patients. The H-13 helicopter, made famous by the film and television versions of M*A*S*H, transported 18,000 wounded soldiers during the conflict. The work of the Medical Air Evacuation Squadrons was a success and was repeated by U.S. forces in Vietnam. The use of helicopters for emergency medical evacuations extended to civilian practice by groups such as the Shock Trauma Air Rescue Society.

Move to life saving, not just transporting

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 vehicles

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.

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 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.

Safety

Like all vehicles, ambulances may be involved in collisions. Ambulances, like other emergency vehicles, are required to operate in all weather conditions, including those during which civilian drivers often elect to stay off of the road. Also, the ambulance crew's responsibilities to their patient often preclude their use of safety devices such as seat belts. Research has shown that ambulances are more likely to be involved in motor vehicle collisions resulting in injury or death than either fire trucks or police cars. Unrestrained occupants, particularly those riding in the patient-care compartment, are particularly vulnerable. When compared to civilian vehicles of similar size, one study found that on a per-accident basis, ambulance collisions tend to involve more people, and result in more injuries. An eleven-year retrospective study concluded in 2001 found that although most fatal ambulance crashes occurred during emergency runs, they typically occurred on improved, straight, dry roads, during clear weather. Safety is thus of special concern in ambulance design.

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 ASHICE message to alert the hospital of the impending arrival of a critical patient.) More recently many services world wide have moved from traditional UHF/VHF sets, which can be monitored externally, to more secure systems, such as those working on a GSM system, such as TETRA
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 scene, or fulfill any other computer based function.
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, or in some cases (dependent on local laws) to prove or disprove cases where a member of crew stands accused of malpractice.
Tail lift or ramp – Ambulances can be fitted with a tail lift or ramp in order to facilitate loading a patient without having to undertake any lifting. This is especially important where the patient might be obese. There may also be equipment linked to this such as winches which are designed to pull heavy patients in to the vehicle.
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.
Air conditioning – Ambulances are often fitted with a separate air conditioning system to serve the working area from that which serves the cab. This helps to maintain an appropriate temperature for any patients being treated, but may also feature additional features such as filtering against airborne pathogens.

Intermediate technology

In parts of the world which lack a high level of infrastructure, ambulances are designed to meet local conditions, being built using intermediate technology. Ambulances can also be trailers, which are pulled by bicycles, motorcycles, tractors, or animals. Animal-powered ambulances can particularly useful in regions that are subject to flooding. Three-wheeled motorcycles are also used, though they are subject to some of the same limitations as more traditional over-the-road ambulances. The level of care provided by these ambulances varies between merely providing transport to a medical clinic to providing on-scene and continuing care during transport.

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.

Appearance and markings

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.

Passive visual warnings

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).

Active visual warnings

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.

Audible warnings

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.

Service providers

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 service of the area, these ambulances are funded by local or national government. In some countries, these only tend to be found in big cities, whereas in countries such as Great Britain almost all emergency ambulances are part of a national health system.
Fire or Police Linked Service – In countries such as the U.S. and France ambulances can be operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. In some cases this can lead to an illness or injury being attended by a vehicle other than an ambulance, such as a fire truck.
Volunteer Ambulance Service – Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service across the world on a volunteer basis. (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance and the Order of Malta Ambulance Corps. These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of Australia and in Ireland.
Private Ambulance Service – Normal commercial companies with paid employees, but often on contract to the local or national government. 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 just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies.
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 size or budget does not warrant 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.
Charity Ambulance – This special type of 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 UK's 'Jumbulance' project.
Company Ambulance - Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries 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 vehichles in the event of a fire or explosion.

Costs

The cost of an ambulance may be paid for from several sources, and this will depend on the type of service being provided, by whom, and possibly who to.

Government funded service – The full cost of the ambulance is borne by the local or national government, with no cost a point of care. One example of this is in the United Kingdom, where ambulances are provided as of right, to anyone who requests one, with costs bourne centrally from taxation as part of the National Health Service
Privately funded service – The 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
Combined system – Ambulances may be free of charge to those who cannot pay (such as those who receive government welfare payments), but chargeable to those who can afford it, or who are insured. It can be the case that a free government provided system may be charged for if the patient is not found to be in genuine need, or they already have insurance which covers them.
Charity funded service – Ambulances may be provided free of charge to patients by a charity, although donations may be sought for services received.
Hospital funded service – Hospitals may provide the ambulances free of charge, on the condition that patient's use the hospital's services (which they may have to pay for). In China, where this is the case, there have been reported incidents where a hospital which was not permitted to run an ambulance service illegally did so, in an effort to increase its business.

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), although response cars may have a sole crew member, possibly backed up by another double-crewed ambulance. It may be the case that only the attendant need be qualified, and the driver might have no medical training.

Common ambulance crew qualifications are:

First Responder – A person who arrives first at the scene of an incident, and whose job is to provide early critical care such as CPR or using an 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.
Ambulance Driver – Some services employ staff with no medical qualification (or just a first aid certificate) whose job is to simply drive the patients from place to place.
Ambulance Care Assistant – Have varying levels of training across the world, but these staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. Dependent on provider, they may be trained in first aid or extended stills such as use of an AED, oxygen therapy and other life saving or palliative skills. They may provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.
Emergency medical technician – Also known as Ambulance Technician. Technicians are usually able to perform a wide range of emergency care skills, such as defibrillation, spinal care, and oxygen therapy. Some countries split this term in to levels (such as in the US, where there is EMT-B and EMT-I).
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), intubation and other skills such as performing a cricothyrotomy. Dependent on jurisdiction, Paramedic can be a protected title, and use of it without the relevant qualification may result in criminal prosecution.
Emergency Care Practitioner – This position, sometimes called 'Super Paramedic' in the media, 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, and are trained to prescribe medicines (from a limited list) for longer term care, such as antibiotics, as well as being trained in a range of additional diagnostic techniques.
Registered nurse (RN) – Nurses can be involved in ambulance work, and as with doctors, this is mostly as air-medical rescuers or critical care transport providers, often in conjunction with a technician or paramedic. They may bring extra skills to the care of the patient, especially those who may be critically ill or injured in locations that do not enjoy close proximity to a high level of definitive care such as trauma, cardiac, or stroke centers.
Doctor – Doctors are present on ambulances – most notably air ambulances – will employ physicians to attend on the ambulances, bringing a full range of additional skills such as use of prescription medicines.

Military use

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.