Ambulance: Wikis

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A modern van based ambulance in Czech Republic
Ambulance response scooter in Israel.
A helicopter used as an air ambulance in Austria.
Boat emergency ambulance in the Scilly Isles.

An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury,[1] and in some instances will also provide out of hospital medical care to the patient. The word is often associated with road going emergency ambulances which form part of an emergency medical service, administering emergency care to those with acute medical problems.

The term ambulance does however extend to a wider range of vehicles other than those with flashing warning lights and sirens, including a large number of non-urgent ambulances which are for transport of patients without an urgent acute condition and a wide range of vehicles including trucks, vans, bicycles, motorbikes, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships.

Contents

The term ambulance comes from the Latin word ambulare, meaning to walk or move about[2] 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.[3] During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons.[4] Field hospitals were still called ambulances during the Franco-Prussian War[5] of 1870 and in the Serbo-Turkish war of 1876[6] even though the wagons were first referred to as ambulances about 1854 during the Crimean War.[7]

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. 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.[8] Such vehicles are called fly-cars. In these cases a patient who requires transportation to hospital will require a patient-carrying ambulance to attend in addition to the fast responder.

History

Early car-based ambulances like this 1948 Cadillac Meteor were sometimes also used as hearses.

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 the 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 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 aircrafts (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.[10] These are usually based on a bus.

Vehicle types

Response bicycle of the London Ambulance Service
Mass casualty ambulance and first Aid Treatment Centre operated by St John Ambulance
Ambulance trailer, designed to be towed by tractor, on the island of Sark

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 ambulance is based on either the chassis of a van, or that of a pickup truck. This chassis is then modified to the designs and specifications of the purchaser.
  • Car/SUV – Used either as a fly-car for rapid response[8] 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[11] as they can travel through heavy traffic much faster than a car or van. Trailers or sidecars can make these patient transporting units.[12][13]
  • Bicycle – Used for response, but usually in pedestrian only areas where large vehicles find access difficult.[14][15] Like the motorcycle ambulance, a bicycle may be connected to a trailer for patient transport, most often in the developing world.[16]
  • All-terrain vehicle (ATV) – for example quad bikes; these are used for response off road,[17] 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.[18] 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.[19]
  • Fixed-wing aircraft – These can be used for either acute emergency care in remote areas (such as in Australia, with the 'Flying Doctors'[20]) or for patient transport over long distances (usually a re-patriation following an illness or injury in a foreign country[21]).
  • Boat – Boats can be used to serve as ambulances, especially in island areas[22] or in areas with a large number of canals, such as the Venetian water 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,[23] although some ships are operated by charities.[24] 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.
  • 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 centres.[25][26]
  • Trailer - In some instances a trailer, which can be towed behind a self-propelled vehicle can be used. This permits flexibility in areas with minimal access to vehicles, such as on small islands.[27]
  • Horse and Cart - Especially in developing world areas, more traditional methods of transport include transport such as horse and cart, used in much the same way as motorcycle or bicycle stretcher units to transport to a local clinic.

Design and construction

Car based ambulance in Sweden
Truck based ambulance in the United States using a pre-built box system

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[28] 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.[29]

Ambulances often have two manufacturers. The first is frequently a manufacturer of light trucks or full-size vans (or previously, cars) such as Mercedes-Benz, Nissan, Toyota, or Ford.[30] The second manufacturer (known as second stage 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,[31][32] 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.[33][34] The type of engine may be determined by the manufacturer: in the past two decades, Ford[35][36][37] 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.[38]

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Safety

Ambulances, like other emergency vehicles, are required to operate in all weather conditions, including those during which civilian drivers often elect to stay off 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.[39] 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.[40] An 11-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.[41] Furthermore, paramedics are also at risk in ambulances while helping patients, as 27 paramedics have died during ambulance trips in the US since 1991.[42]

Equipment

Modern ambulance equipment
Ambulance Interior Details.jpg
Interior of a mobile intensive care unit (MICU) ambulance from Graz, Austria
Four stages of deployment on an ambulance tail lift

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.)[28][29] 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.[43]
  • 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.[44]
  • 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,[45] 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 is obese or specialty care transports that require large, bulky equipment such as an neonatal incubator or hospital beds. There may also be equipment linked to this such as winches which are designed to pull heavy patients in to the vehicle.[46]
  • 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.
  • 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.[47]

Intermediate technology

A modern motorcycle ambulance in Southern Sudan.

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 be particularly useful in regions that are subject to flooding. Motorcycles fitted with sidecars (or motorcycle ambulances) 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.[12]

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.[13][48]

Appearance and markings

An ambulance in Great Britain marked with passive visual warnings (retro-reflective battenburg pattern)

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 sign ('give way')[49], or be permitted to break the speed limit.[50] Generally, the priority of the response to the call will be assigned by the dispatcher, but the priority of the return will be decided by the ambulance crew based on the severity of the patient. Patients in significant danger to life and limb (as determined by triage require urgent treatment by advanced medical personnel[51], and because of this need, emergency ambulances are often fitted with passive and active visual and/or audible warnings to alert road users.

Passive visual warnings

An ACT ambulance with activated emergency lights and reflective markings.
NWAS ambulance displays reversed wording and Star of Life. The single illuminated headlamp is probably not due to one headlamp being burned out, but rather due to the use of a wig-wag.

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 reflects 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.

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 an emergency telephone number for the ambulance service.

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, 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[52], because the Red Cross symbol is legally protected by both National[53] and international[54][55] law. 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.[56][57][58][59]

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).[60]

Active visual warnings

British ambulance with roof-mounted LED lightbar, dashboard beacon, grill lights (not active on photo) and wig-wag. The dashboard beacon is placed equivalently in a car's rear mirror height giving the ambulance maximum visibility.

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 the colours may vary by country and sometimes by operator.

There are several technologies in use to achieve the flashing effect. These incluse flashing a light bulb or LED, and strobe lights, which are usually brighter than incandescent lights. Each of these can be programed to flash singly or in groups, and can be programmed to flash in patterns (such as a left -> right pattern for use when the ambulance is parked on the left hand side of the road, indicating to other road users that they should move to the right (away from the ambulance)). Incandescent and LED lights may also be programed to burn steadily, without flashing.

Emergency lights may be housed in special fittings, such as in a lightbar, or may be hidden in a host light (such as a headlamp) by drilling a hole in the host light's reflector and inserting the emergency light. These hidden lights may not be apparent until they are activated. Additionally, some of the standard lights fitted to an ambulance (e.g. headlamps, tail lamps) may be programed to flash. Flashing headlights (typically the high beams, flashed alternately) are known as a wig-wag.

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.

See also Emergency vehicle equipment.

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, producing a range of different noises which ambulance operators can use to attract more attention to themselves, particularly when proceeding through an intersection or in heavy traffic.[61]

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).[62] 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, those not using a compatible radio or even have it turned off.[63]

Service providers

A volunteer ambulance crew in Modena, Italy
A city fire service ambulance from the Tokyo Fire Department.
Non-acute patient transport ambulance from New Zealand.

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.

  1. 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 nationwide system under the National Health Service.[64]
  2. Fire or Police Linked Service – In countries such as the United States, Japan, 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.
  3. 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 department, 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.[65] (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance[66] and the Order of Malta Ambulance Corps.[67] 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.
  4. 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, in many areas private services cover all emergency transport functions and government agencies do not provide this service. Companies such as Falck and American Medical Response, are two of the larger companies that provide such services. In many service areas private firms provide first tier response to emergency calls. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events .[68]
  5. 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.
  6. 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.
  7. 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.[10]
  8. 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 vehicles 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 or the majority of the cost of the ambulance is borne by the local, regional, or national government (through their normal taxation).[69]
  • 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.[70]
  • Charity funded service – Ambulances may be provided free of charge to patients by a charity, although donations may be sought for services received.[71]
  • Hospital funded service – Hospitals may provide the ambulances free of charge, on the condition that patients use the hospital's services (which they may have to pay for).[72]

Crewing

Ambulance crew
Scottish Ambulance Service "First Responder" vehicle

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. In some locations, an advanced life support ambulance may be crewed by one paramedic and one EMT-Basic.

Common ambulance crew qualifications are:

  1. First responder – A person who arrives first at the scene of an incident,[73] 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.
  2. 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. In some emergency ambulance contexts this term is a pejorative toward qualified providers implying that they perform no function but driving, although it may be acceptable for patient transport or community operations.
  3. 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.[74] 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.
  4. 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 immobilization, bleeding control, splinting of suspected fractures, assisting the patient with certain medications, and oxygen therapy. Some countries split this term in to levels (such as in the US, where there is EMT-Basic and EMT-Intermediate).[75]
  5. 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.[76] Dependent on jurisdiction, the title "paramedic" can be a protected title, and use of it without the relevant qualification may result in criminal prosecution.[77]
  6. 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.[78] 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.
  7. 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,[79] 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.
  8. Doctor – Doctors are present on some ambulances – most notably air ambulances[80][81] – will employ physicians to attend on the ambulances, bringing a full range of additional skills such as use of prescription medicines.

Military use

An URO VAMTAC ambulance of the Spanish Army emblazoned with the Red Cross
A Danish Air Force VW Transporter ambulance on a traditional civilian van based chassis
USNS Mercy, a U.S. Navy hospital ship
See also: United States Army Ambulance Service (World War I)

Military ambulances include both ambulances based on civilian designs and armored, but unarmed ambulances based upon armoured personnel carriers (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.[82]

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.[83] 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 catching enemy fire —accidental or deliberate. As a result, medics and other medical personnel attached to military ambulances are usually put through basic military training,[84] on the assumption that they may have to use a weapon. The laws of war does allow non-combatant military personnel to carry individual weapons for protecting themselves and casualties. It is however not all militaries who exercise this right to their personnel.

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.[85] The modifications were made following a failed rescue attempt in which Palestinian gunmen killed two soldiers who was providing aid for a Palestinian woman in Rafah.[86] Since M-113 armored personnel carriers and regular up-armored ambulances are not sufficiently protected against anti-tank weapons and improvised explosive devices,[87] 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[citation needed].

Some navies operate ocean-going hospital ships to lend medical assistance in high casualty situations like wars or natural disasters.[23] These hospital ships fulfill 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.[88]

See also


References and notes

  1. ^ Skinner, Henry Alan. 1949, "The Origin of Medical Terms". Baltimore: Williams & Wilkins
  2. ^ "How Products Are Made: Ambulance". How products are made. http://science.enotes.com/how-products-encyclopedia/ambulance. Retrieved 2007-06-02. 
  3. ^ Oxford English Dictionary ambulance definition 1
  4. ^ Civil War Ambulance Wagons
  5. ^ The memoirs of Charles E. Ryan With An Ambulance Personal Experiences And Adventures With Both Armies 1870-1871 [1] and of Emma Maria Pearson and Louisa McLaughlin Our Adventures During the War of 1870 [2]
  6. ^ Emma Maria Pearson and Louisa McLaughlin Service in Servia Under the Red Cross [3]
  7. ^ Oxford English Dictionary ambulance definition 2a
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External links


1911 encyclopedia

Up to date as of January 14, 2010

From LoveToKnow 1911

Medical warning!
This article is from the 1911 Encyclopaedia Britannica. Medical science has made many leaps forward since it has been written. This is not a site for medical advice, when you need information on a medical condition, consult a professional instead.

AMBULANCE (from the Fr. ambulance, formerly hopital ambulant, derived from the Lat. ambulare, to move about), a term generally applied in England and America to the wagon or other vehicle in which the wounded in battle, or those who have sustained injuries in civil life, are conveyed to hospital. More strictly, in military parlance, the term imports a hospital establishment moving with an army in the field, to provide for the collection, treatment and care of the wounded on the battlefield, and of the sick, until they can be removed to hospitals of a more stationary character. In 1905-1906 the term "field ambulance" was adopted in the British service to dente this organization, the former division of the ambulance service into "bearer companies" and "field hospitals" being done away with. The description of the British service given below applies generally to the system in vogue in the army after the experience gained in the South African War of 1899-1902; but in recent years the medical arrangements in connexion with the British army hospitals have been altered in various details, and the changes in progress showed no sign of absolute finality. Some of these, however, were rather of nomenclature than of substance, and hardly affect the principles as described below.

The ambulance organization which, variously modified in details, now prevails in all civilized armies, only dates from the last decade of the 18th century. Before that time wounded soldiers were either carried to the rear by comrades or left unattended to and exposed until the fighting was over. Surgical assistance did not reach the battlefield till the day after the engagement, or even later; and for many of the wounded it was then too late. In 1792 Baron Dominique Jean Larrey (1766-1842) of the French army introduced his system of ambulances volantes, or flying field hospitals, capable of moving with speed from place to place, like the "flying artillery" of that time. They were adapted both for giving the necessary primary surgical treatment and for removing the wounded quickly from the sphere of fighting. Napoleon warmly supported Larrey in his efforts in this direction, and the system was soon brought to a high state of efficiency in the About the same time another distinguished surgeon in the French army, Baron Pierre Francois Percy (1754-1825), organized a corps of brancardiers, or stretcher-bearers. These were soldiers trained and equipped for the duty of collecting the wounded while a battle was in progress, and carrying them to a place of safety, where their wounds and injuries could be attended to. An important step towards the amelioration of the condition of the wounded of armies in the field was the European Convention signed at Geneva in 1864, by the terms of which, subject to certain regulations, not only the wounded themselves but also the official staff of ambulances and their equipment were rendered neutral, the former, therefore, not being liable to be retained as prisoners of war, nor the latter to be taken as prize of war. This convention has greatly favoured the development of ambulance establishments, but as all combatants have not the same knowledge of the conditions of this convention, or do not interpret them in the same way, charges of treachery and abuse of the Red Cross flag are but too common in modern warfare.

The American Civil War marked the beginning of the modern ambulance system. The main feature, however, of the hospital organization throughout that war was the railway hospital service, which provided for the rapid conveyance of the sick and wounded to the rear of the contending armies. Hospital carriages, equipped with medical stores and appliances, for the transport of cases from the front to the base, were rapidly introduced into other armies, and played a great part in the ambulance service of the Franco-German War.

The German hospital service as existing at the time of the Franco-German War of 1870-71 was modified and extended by the Kriegs Saniteits Ordnung of 1878 and the Kriegs Etappen Ordnung of 1887, which completed the organization by the addition in time of war of numerous subordinate offices and departments. The main divisions of the ambulance organization of the German army in the field fall into: (1) sanitary detachments, (2) field hospitals, (3) flying hospitals, (4) hospital reserve depots, (5) "committees for the transport of the sick," and (6) railway hospital trains. The whole administration of the ambulance service of the grand army in the field is in the hands of the chief of the ambulance sanitary staff, who is attached to headquarters. Next in command come surgeonsgeneral of armies in the field, surgeons-general of army corps, and under them again surgeons-in-chief of divisions and regiments. Civil consulting surgeons of eminence, and professors from the universities, are also attached to the various armies and divisions to co-operate with and act as advisers to the surgeons of the standing military surgical staff. The hospital transport service on the lines of communication is highly organized and the hospital railway carriages are elaborately equipped. French The French ambulance system, finally settled by the reglement of 1884, is organized on almost identical lines with the German; one of the principal peculiarities of the former being the ambulances volantes already referred to. The peace I. 26 organization of the German and French systems does not materially differ from that of the British service.

In the Japanese army a special feature is the sanitary corps, whose duty is the prevention of disease among the troops; it has been brought to a great pitch of perfection, with the result that in the Russo-Japanese War (1904-1905) the immunity of the troops from all forms of preventable disease surpassed all previous experience. Not only was the army accompanied by sanitary experts who advised on all questions of camping grounds, water supply, &c., but before the war began the Intelligence Department collected information as to the diseases of the country likely to be the scene of operations, unhealthy places to be avoided, and precautions to be taken.

Coming now to the ambulance system of the British army, in which are comprised the arrangements and organization of the medical department for the care and treatment of the sick and wounded from the time they are injured or taken ill, till they are able to return to duty or are invalided home, we will trace the progress of a wounded man from the field of battle to his home; remembering that, as British troops are usually engaged overseas, hospital ships as well as land transport are necessary.

When a soldier falls wounded in action he is attended by the regimental surgeon and stretcher-bearers, who apply some extemporized method of stopping bleeding and dress the wounds with the "first field dressing" - a packet of antiseptic material which every officer and man on active service carries stitched to some part of his clothing, and which contains everything necessary for dressing an ordinary gunshot wound. Recent wars have demonstrated that in all uncomplicated cases it is better to leave this dressing undisturbed, as the wounds made by modern projectiles heal up at once if left alone, if air and dirt have been thus excluded. From the field he is carried on a stretcher by bearers (formerly of the "Bearer Companies") of the Royal Army Medical Corps to the collecting station, where he is placed on an ambulance wagon of the first line of assistance and taken to the dressing station. Here his wound will be examined if considered necessary, but as on the field the first medical officer who examined him has already attached a "specification tally" to the patient, giving particulars of the wound, it will probably not be disturbed unless complicated by bleeding, splintering of bone or some other condition requiring interference. Any operation, however, which is urgently called for will be here performed, nourishment, stimulants and opiates administered if required, and the patient moved to the field hospital in an ambulance wagon of the second line of assistance. From the field hospital he is transferred as soon as possible by the ambulance train to the general hospital at the advanced base of operations, and from there in due time in another train to the base of operations at the coast, from which he is ultimately either returned to duty or sent home in a hospital ship. The organization by which these requirements are fulfilled is the following: - Every regiment and fighting unit has posted to it, on proceeding on active service, a medical officer who looks of ter the health of the men and advises the commanding officer on sanitary matters.

Regi- When the regiment goes into action he takes command of the regimental stretcher-bearers who, to the number of two per company, have been in peace time instructed in first aid and in the carrying of the wounded on stretchers. These men leave their arms behind and wear the Red Cross armlets, to indicate their non-combatant functions, but in these days, when a battle is often fought at long ranges, it is not to be wondered at, or attributed to disregard of the red cross flag by the enemy, if medical officers and stretcher-bearers are hit. The bearer company into whose charge the wounded man next passes is composed of men of the Royal Army Medical Corps, with a detachment of the Army Service Corps for transport duties. In future, bearer sections of the Field Ambulances will perform the duties of the bearer company. Its function is to collect and succour the wounded on the battlefield and to hand them over to the field hospitals, with which these bearer corn panies are closely associated, though separately organized. In the Indian army the bearer company is provided from the personnel of the field hospital when there is a battle, and reverts to the hospital again after it is over. The war in South Africa of 1899-1902 clearly demonstrated the superiority of the Indian plan; for after the action the bearer company staff should be available to give the much-needed help in the field hospital, and some amalgamation of the two organizations, or something after the plan of the ambulance volante of the French, is necessary. The bearers afford the wounded any treatment required, supply water and sedatives, and then carry them back on stretchers to the collecting station in the rear, whence they are conveyed to the dressing station in the wagons or other form of transport.

At the dressing station, which ought to be out of range of the firing, and should have a good water supply, the patient is made as comfortable as possible, nourishment and stimulants are administered, and he is then taken to the field hospital. In times of great stress, when it is desirable to remove the wounded quickly from the field, and there are no roads or wheeled transport is not available, large numbers of bearers are employed to carry them on stretchers, &c. These men are engaged locally and are soon given the slight training necessary. This was done in Natal after the battles on the Tugela (1899), in which there were some thousands of wounded to be conveyed; also in Egypt, where the local troops not required for the fighting line were requisitioned; the Japanese in Mongolia employed hundreds of Chinese coolies for this purpose, the general use of sedan-chairs in China having accustomed the poorer class of natives to this kind of labour. In India, the rank and file of the Royal Army Medical Corps not being employed, the bearer work is carried out by natives specially enlisted and I organized into a corps. These men are bearers by caste - a reminiscence of the system which prevailed generally a hundred years ago, and is still met with in out-of-the-way places,. of conveyance of travellers in dhoolies, which are closed wooden carriages fixed on long poles and carried on men's shoulders. The bearers convey the wounded in dandies, similar to dhoolies,. but made mostly of canvas, so that they are much lighter. The courage of these bearers on the battlefield has often been praised. The old bearer caste is, however, rapidly dying out owing to the general discontinuance of the use of dhoolies. Thus the ambulance organization in India is entirely different from that in other parts of the British empire. The rank and file of the Royal Army Medical Corps are not employed there, although the medical officers are. The warrant and non-commissioned ranks are replaced by a most useful body of men of Anglo-Indian or Eurasian (half caste) birth, called the Subordinate Medical Department, the members of which, now called assistant surgeons (formerly apothecaries), receive a three years' training in medical work at the Indian medical schools and are competent to perform the compounding of medicines and to deal with all but the most serious cases of injury and illness. In the hospitals the men of the Royal Army Medical Corps are replaced by the Native Army Hospital Corps, subdivided into ward-servants, cooks, watercarriers, sweepers and washermen. The caste system necessitates this division of labour, and the men are not so efficient or trustworthy as the white soldiers whose places they take. The bearers of the wounded are a separate and distinct class, partly attached to regiments, &c., as part of the regimental transport, and partly organized into bearer companies, attached to field hospitals. The dandies in which they carry the wounded are much more comfortable than stretchers, being fitted with roofs and sides of canvas to keep off sun and rain, thus being collapsible so that the dandy is quite flat when not in use. Still they are heavy, clumsy, and cannot be folded up into a small compass for transport like a stretcher; they also take up a good deal of room in wagons and can scarcely be carried on the backs of animals owing to the length of the pole. Hence riding ponies and mules are much used in Indian warfare, especially in the mountains, for the carriage of less seriously wounded men. In India separate hospitals are necessary for white and native troops, and the latter have accommodation for the large numbers of non-combatant camp-followers, mule-drivers, cooks, officers' servants, &c., &c., which constitute one of the most remarkable features of the Indian army organization.

Field hospitals, under the new scheme furnished by tent sections of the Field Ambulances, are each supposed to provide accommodation for 100 patients, who live on their field medical comforts. The patients are not supplied with hospital clothing, nor do they have beds, but lie on straw, which is spread on the ground and covered with waterproof sheets and blankets; of these latter a considerable reserve is carried. These hospitals can and must at times accommodate more than the regulation number of patients, but in the South African War their resources were at times considerably overtaxed, with consequent discomfort and hardship to the patients, the medical equipment proving insufficient for unexpectedly heavy calls upon its resources. These hospitals are supposed to move with the army, and therefore it is imperative to pass the wounded quickly back from these to the stationary hospitals on the lines of communication (which vary according to the length of these lines) and thence to the general hospitals at the base. The size of the lines of communication hospitals varies according to circumstances, and they are as a rule "dieted," that is to say, proper hospital diets and not field rations are issued to the patients, who also are supplied with beds and proper hospital clothing. In these hospitals also there may be nursing sisters, who of course are unsuited for the rough work and life nearer the front. Sisters are also employed on the hospital trains, which were found most useful and brought to great perfection in the South African War, being fitted with beds, kitchens, dispensaries, &c., so that patients were moved long distances in comfort.

Arrived at the base of operations the wounded are admitted to the general hospitals, of which the numbers and situation vary with circumstances, but each is supposed to Civil tinned the Princess Christian, the Imperial Yeomanr y Y (both field and general hospitals), the Langman, the Portland, the Scottish, Irish and Welsh hospitals. These were staffed entirely by civilians, except that an officer of the Royal Army Medical Corps was attached to each as administrator and organizer; and their personnel was made up of physicians, surgeons, nurses, dressers (medical students and in some cases fully qualified surgeons) and servants; the numbers, of course, varying with the size of the hospitals. In addition to the staff of these hospitals several eminent civil surgeons, including Sir William MacCormac and Sir F. Treves, went out to the seat of war as consultants: an innovation in the British service, but in accordance with the system long in vogue in Germany.

To the Army Medical organization is affiliated in war time that of the Red Cross Society and other charitable associations, which during the South African War aided the Army Medical Service greatly by gifts of clothing, money and numerous luxuries for the sick and wounded.

Lastly, the wounded man is transferred to a hospital ship, which is fitted up with comfortable swinging cots in airy wards, with refrigerators for preserving provisions and the division of an army corps is supposed to have one such ship, with from 200 to 250 beds and the same staff of doctors, nurses, &c., as a hospital of similar size on shore, when necessary.

Different regulations are made by various powers as to the work of the Red Cross societies under the Geneva flag. Whereas in Germany and France such aid is officially recognized andlaced under direct military control the En lish P Y ? g Red Cross societies have acted side by side with, but independently of, the military ambulance organization. In the South African War (1899-1902), however, the bonds of union were drawn considerably closer, and cordial co-operation was brought about to prevent overlapping and waste of money. In Germany the volunteer organization is presided over by an imperial commission or inspector-general appointed in peace time, who in time of war is attached to the headquarters staff. His functions are to control the relations of the various Red Cross societies and secure harmonious co-operation. Delegates appointed by him are attached to the various corps and transport commissions. No volunteer assistance can be utilized which is not entirely subordinate to the military control, and has not already in peace time received official recognition and been organized on a skeleton footing. Moreover, only persons of German nationality can be employed under it with the armies in the field. In case of base hospitals situated in Germany itself, the services of foreigners may be employed when specially authorized by the war office. In France, in the main, the same rules obtain in the case of volunteer hospital service.

Great attention has been paid to civil ambulance organization in England. In 1878 the British ambulance association of St John of Jerusalem was founded. Its object was to St. render first aid to persons injured in accidents on the road, railway, or in any of the occupations of civil life.

As the result of the initiative taken by this society, ambulance corps have been formed in most large towns of the United Kingdom; and police, railway servants and workmen have been instructed how to render first aid pending the arrival of a doctor. This samaritan work has been further developed and extended to most parts of the British empire, notably Canada, Australia and India, and there is no doubt that many lives are saved annually by the knowledge, diffused by this association, as to how to stop bleeding, resuscitate the apparently drowned, &c. Moreover, during the South African War this association provided a most valuable reserve for the Royal Army Medical Corps, and drafted out some hundreds of partially trained men whose assistance was most valuable to the Army Medical Service in dealing with the enormous numbers of sick and wounded who came upon their hands.

In America each city has its own system and organization of civil ambulance service. In some, as in Boston, the service is worked by the police; in others, notably New York, civil by the hospitals, while Chicago has an admirable service under municipal control. In most of the lance in capitals of Europe similar systems prevail. America.

British ambulance wagons are built very strongly to stand rough roads, and are of several patterns; those used in the war in South Africa were reported on as heavy, uncomfortable, and so unwieldy as to be incapable very often of ante - keeping up with the troops; but a new and more mobile vehicle, to convey four patients lying down as well as six seated, or fourteen all seated (whereas the old pattern wagons only accommodated two lying-down cases), has been introduced. All patterns of wagons weigh from 172 to 182 cwt., while the Boers and the British Colonial auxiliaries used much lighter carts, which were taken at a gallop over almost any country. The Indian ambulances are small two-wheeled carts, called tongas, drawn by two bullocks or mules; very strongly made, they are capable of holding two men lying down, or four sitting up, besides the native driver.

Various other forms of transport are found, such as mule litters in mountainous districts, where wheeled carriages cannot go, camel litters in the Sudan, dhoolies in India, hammocks on the west coast of Africa, or sedan-chairs in China. In the RussoJapanese War an ingenious form of mule litter for serious cases 'on ' Field rations suitably cooked and supplemented by various Y PP Y owing to the inability of the comparatively small Royal Army Medical Corps to meet all the requirements of the enormous force which was ultimately employed, many of the doctors were drawn from the civil profession, and the rank and file from the St John's Ambulance Association and the Volunteer Medical Staff Corps, while many nursing sisters belonged to the Army Nursing Reserve, ordinarily employed in civil hospitals but liable to be drafted out during war. In the South African War the patriotism and liberality of the British public furnished several large general hospitals, perfectly equipped, and officered by some of the most eminent members of the medical profession in the United Kingdom. Among others may be men have an officers' ward. In the South African War, supply of ice, punkahs for hot weather, &c. Each PP Y P was made by fixing the ends of two long springy poles about 15 ft. long into each side of the pack saddles of two mules, one in front of the other, so as to support a bed for the patient between them; the length and resiliency of the poles prevented jolting of the wounded man, and the mules were able to carry him long distances over any kind of ground. The ordinary mule or camel litter provides for a wounded man (lying down) being carried on a sort of stretcher on either side of the animal, or in cacolets in which the less serious cases are slung in seats (one on each side of the animal), sitting up.

In Great Britain, the material and equipment required are stored in times of peace at the various headquarters stations and carefully examined twice a year; and on orders for mobilization being issued the doctors and various tiov. g, ranks of attendants, who have previously been told off to each unit, repair to the allotted station, draw the equipment and transport, and embark with the brigade to which they are attached. The tendency of the present day is towards reduction in bulk and concentration of strength of drugs, points which simplify the question of transport of ambulance material. As the fighting man can carry concentrated nourishment enough for thirty-six hours, in the form of an emergency ration, in a tin the size of an ordinary cigar-case, and enough sweetening material in the form of saccharine to last a fortnight in a bottle smaller than an ordinary watch, so the medical department can take their drugs in the form of compressed tabloids, each the correct dose, and each occupying about onetenth of the space the drug ordinarily would; while the medical officers can carry hypodermic cases, not so large as an ordinary cigarette-case, containing a syringe and hundreds of doses of highly concentrated remedies. Again, the traction engines which now accompany an army can also supply electricity for X-ray work, electric-lighting, ice-making, &c. (J. R. D.)


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Simple English

, Mexico]] An ambulance is a type of vehicle made to carry sick or injured people. Normally, ambulances go to people in emergencies to take people to hospital. Examples of emergencies include serious broken bones, chest pain, serious head injuries, and people injured in situations like car crashes.

Ambulances normally have emergency medical technicians (EMTs) and paramedics who work on them. The are highly trained to provide emergency care and treatment before reaching hospital.

They carry a lot of special equipment that can keep people alive, by giving them oxygen, restarting their heart if it stops, or repairing a collapsed lung.

Ambulances are normally called by dialing a special emergency number, which is different from country to country. In the UK, this number is 999; USA 911; Europe 112.

Air ambulance

Air ambulances have been important for the last twenty years, with quick, or out-of-town medical support becoming a necessity. Both helicopters and jets are generally outfitted with the same kind equipment that you see in a typical ground ambulance. In the United States, the Coast Guard runs a public air ambulance service using helicopters. There are also privately owned air ambulance services that provide for a wider range of needs, including international transport.


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