View source for Emergency medical services

{{Short description|Services providing acute medical care}}
{{Distinguish|text= [[Emergency Hospital Service]], also known as the Emergency Medical Service, which operated in World War II Britain}}
{{Use dmy dates|date=January 2025}}
[[File:1 E1C4007 (20885690376).jpg|thumb|[[Chicago Fire Department]] paramedics transporting a patient on a [[stretcher]]]]
[[File:NSW Ambulance Australia.png|thumb|A [[New South Wales Ambulance]] emergency medical services unit responding to a [[call for service]]]]
[[Image:Ambulanza Italiana 2010 vano sanitario.jpg|thumb|Typical interior view of an Italian ambulance]]
'''Emergency medical services''' ('''EMS'''), also known as '''ambulance services''', '''pre-hospital care''' or '''paramedic services''', are [[emergency service]]s that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care.<ref>{{cite web|title=What is EMS?|publisher=NHTSA|url=https://www.ems.gov/whatisems.html|access-date=11 November 2018|archive-date=5 April 2019|archive-url=https://web.archive.org/web/20190405192040/https://www.ems.gov/whatisems.html}}</ref> They may also be known as a first aid squad,<ref>{{cite web|url=http://www.longhillnj.org/firstaid/firstaid.main.html|archive-url=https://web.archive.org/web/20051222193721/http://www.longhillnj.org/firstaid/firstaid.main.html|archive-date=2005-12-22|title=Long Hill Township First Aid Squad|access-date=2007-06-18}}</ref> FAST squad,<ref>{{Cite web|url=http://www.lymenh.gov/fast-squad|title=FAST Squad {{!}} Town of Lyme NH|website=lymenh.gov|access-date=2016-06-01}}</ref> emergency squad,<ref>{{cite web|url=http://www.emergencysquad.org/|title=Hennepin County Emergency Squad|access-date=2007-06-18|archive-url=https://web.archive.org/web/20070615231916/http://www.emergencysquad.org/|archive-date=15 June 2007}}</ref> ambulance squad,<ref>{{cite web|title=Nottingham Ambulance Squad|url=http://www.angelfire.com/nj2/nas/|access-date=2007-06-18|archive-url=https://web.archive.org/web/20070926230015/http://www.angelfire.com/nj2/nas/|archive-date=26 September 2007}}</ref> ambulance corps,<ref>{{cite web|title=Valhalla Volunteer Ambulance Corps|url=http://members.aol.com/oreilly7/vvac/|archive-url=https://web.archive.org/web/20080706231902/http://members.aol.com/oreilly7/vvac/|archive-date=2008-07-06|access-date=2007-06-18}}</ref> life squad<ref>{{cite web|url=http://www.sardinialifesquad.com/|title=Sardinia Life Squad|access-date=2007-06-18|archive-url=https://web.archive.org/web/20070622175216/http://www.sardinialifesquad.com/|archive-date=22 June 2007|url-status=usurped}}</ref> or by other [[acronym|initialism]]s such as EMAS or EMARS.

In most places, EMS can be summoned by members of the public (as well as medical facilities, other emergency services, businesses and authorities) via an [[emergency telephone number]] which puts them in contact with a dispatching centre, which will then dispatch suitable resources for the call.<ref>{{cite web|url=http://ec.europa.eu/environment/civil/pdfdocs/112surv-2001.pdf/|title=EU document on European adoption of 112 emergency number|access-date=2007-06-29|archive-url=https://web.archive.org/web/20080720213936/http://ec.europa.eu/environment/civil/pdfdocs/112surv-2001.pdf|archive-date=20 July 2008}}</ref> [[Ambulance]]s are the primary vehicles for delivering EMS, though [[Nontransporting EMS vehicle|squad cars]], [[Motorcycle ambulance|motorcycles]], [[Air medical services|aircraft]], [[Water ambulance|boats]], [[Firefighting apparatus|fire apparatus]], and others may be used. EMS agencies may also operate a non-emergency [[patient transport]] service, and some have [[rescue squad]]s to provide [[technical rescue]] or [[search and rescue]] services.<ref>{{cite web|title=EMS Special Operations|url=http://www.colonie.org/ems/#anchor45252|publisher=Town of Colonie EMS|access-date=2007-06-29|archive-url=https://web.archive.org/web/20080108064258/http://www.colonie.org/ems/#anchor45252|archive-date=8 January 2008}}</ref>

When EMS is dispatched, they will initiate medical care upon arrival on scene. If it is deemed necessary or a patient requests transport, the unit is then tasked with transferring the [[patient]] to the next [[point of care]], typically an [[emergency department]] of a [[hospital]]. Historically, ambulances only transported patients to care, and this remains the case in parts of the developing world.<ref name=motorbike>{{cite news|publisher=Transport News Network|date=4 July 2006|url=http://www.tnn.co.uk/WorldwideNews/plonearticle.2006-07-04.2967165399|title=Motorcycle Ambulance Trailer Project Gets Off The Ground With MAN ERF UK|access-date=2008-08-07|archive-url=https://web.archive.org/web/20080922200132/http://www.tnn.co.uk/WorldwideNews/plonearticle.2006-07-04.2967165399|archive-date=22 September 2008}}</ref> The term "emergency medical service" was popularised when these services began to emphasise emergency treatment at the scene. In some countries, a substantial portion of EMS calls do not result in a patient being taken to hospital.<ref>{{Cite news|url=https://www.telegraph.co.uk/news/health/news/10438156/Do-not-take-all-your-patients-to-hospital-paramedics-told.html|archive-url=https://ghostarchive.org/archive/20220112/https://www.telegraph.co.uk/news/health/news/10438156/Do-not-take-all-your-patients-to-hospital-paramedics-told.html|archive-date=12 January 2022|url-access=subscription|url-status=live|title=Do not take all your patients to hospital, paramedics told|date=10 November 2013|access-date=4 July 2018|last1=Donnelly|first1=Laura}}{{cbignore}}</ref>

Training and [[professional certification|qualification]] levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive ambulances, with no medical training.<ref name=motorbike/> In contrast, most systems have personnel who retain at least basic [[first aid]] certifications, such as [[basic life support]] (BLS). In English-speaking countries, they are known as [[emergency medical technician]]s (EMTs) and [[paramedic]]s, with the latter having additional training such as [[advanced life support]] (ALS) skills. [[Physician]]s and [[nurse]]s may also provide pre-hospital care to varying degrees in certain countries, a model which is popular in [[Europe]].

==History==
===Precursors===
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The [[New Testament]] contains the [[parable of the Good Samaritan]], in which a man who has been beaten is cared for by a passing Samaritan. Luke 10:34 (NIV) – "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." During the Middle Ages, the [[Knights Hospitaller]] were known for rendering assistance to wounded soldiers in the battlefield.<ref>{{cite web|url=http://www.medicinenet.com/script/main/art.asp?articlekey=52749|title=Knights Hospitaller's|access-date=2008-08-20}}</ref>

[[File:Larrey%27s_Flying_Ambulance.jpg|thumb|right|200px|A drawing of one of Larrey's ''ambulances volantes'']]
The first use of the ambulance as a specialized vehicle in battle came about with the ''ambulances volantes'' designed by [[Dominique Jean Larrey]] (1766–1842), [[Napoleon]] Bonaparte's chief surgeon.<ref name=fly1>{{cite journal|vauthors=Skandalakis PN, Lainas P, Zoras O, Skandalakis JE, Mirilas P|title='To afford the wounded speedy assistance': Dominique Jean Larrey and Napoleon|journal=World Journal of Surgery|volume=30|issue=8|pages=1392–99|date=August 2006|pmid=16850154|doi=10.1007/s00268-005-0436-8|s2cid=42597837}}</ref><ref name=fly2>{{cite journal|url=http://napoleonic-literature.com/Flying_Ambulance.htm|title=The Revolutionary Flying Ambulance of Napoleon's Surgeon|last=Ortiz|first=Captain Jose M|date=October–December 1998|pages=17–25|volume=8|access-date=9 August 2008|archive-url=https://web.archive.org/web/20080514091424/http://www.napoleonic-literature.com/Flying_Ambulance.htm|archive-date=14 May 2008}}</ref> Larrey was present at the battle of Spires, between the [[France|French]] and [[Prussia]]ns, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system.<ref name=fly1/><ref name=fly2/><ref name=Ambulance>{{cite book|author=Barkley, Katherine|title=The ambulance: the story of emergency transportation of sick and wounded through the centuries|publisher=Exposition Press|location=New York|year=1978|isbn=978-0-682-48983-6}}</ref> Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled [[horse]]-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield ''after'' they had received early treatment in the field.<ref name=fly2/> Larrey's projects for 'flying ambulances' were first approved by the [[Committee of Public Safety]] in 1794. Larrey subsequently entered Napoleon's service during the Italian campaigns in 1796, where his ambulances were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even developing a litter which could be carried by a [[camel]] for a campaign in [[Egypt]].<ref name=fly2/>

===Early civilian ambulances===
A major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for [[cholera]] patients in London during 1832.<ref>{{cite web|url=http://www.earlyamerica.com/review/2000_fall/1832_cholera.html|title=Cholera carriages|access-date=2008-08-09|archive-url=https://web.archive.org/web/20080622015258/http://www.earlyamerica.com/review/2000_fall/1832_cholera.html|archive-date=22 June 2008}}</ref> The statement on the carriage, as printed in ''[[The Times]]'', said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other".<ref name=Ambulance/> This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.

[[File:Bellevue Hospital Ambulance, New York Times, 1895.JPG|thumb|A horse-drawn [[Bellevue Hospital]] ambulance in [[New York City]], 1895|alt=]]
The first known hospital-based ambulance service operated out of Commercial Hospital, [[Cincinnati]], Ohio (now the Cincinnati General) by 1865.<ref>{{cite web|title=A Brief History of EMS|url=https://www.emsmemorial.org/ems-history|publisher=EMS Memorial|access-date=2 May 2025}}</ref><ref name=Ambulance/> This was soon followed by other services, notably the [[New York (state)|New York]] service provided out of [[Bellevue Hospital]] which started in 1869 with ambulances carrying medical equipment,<ref>{{cite web|title=A Brief History of Emergency Medical Services|url=https://wvde.state.wv.us/abe/Public%20Service%20Personnel/HistoryofEMS.html#:~:text=EMS%20in%20America%20can%20be,take%20care%20of%20the%20soldiers.|archive-url=https://web.archive.org/web/20230201091249/https://wvde.state.wv.us/abe/Public%20Service%20Personnel/HistoryofEMS.html|archive-date=1 February 2023|access-date=29 October 2022|publisher=West Virginia Department of Education}}</ref> such as [[Splint (medicine)|splint]]s, a stomach pump, [[morphine]], and [[brandy]], reflecting contemporary medicine.

Another early ambulance service was founded by Jaromir V. Mundy, Count J. N. Wilczek, and [[Eduard Lamezan-Salins]] in [[Vienna]] after the disastrous fire at the [[Ringtheater|Vienna Ringtheater]] in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide.<ref>{{cite web|author=Nicholas Genes|url=http://medgadget.com/archives/2005/09/disasters_and_e.html|title=Disasters and Emergency Medicine|publisher=Medgadget.com|date=2 September 2005|access-date=2012-04-05|archive-url=https://web.archive.org/web/20090612095957/http://www.medgadget.com/archives/2005/09/disasters_and_e.html|archive-date=12 June 2009}}</ref>

In June 1887 the [[St John Ambulance (England and the Islands)|St John Ambulance Brigade]] was established to provide first aid and ambulance services at public events in [[London]].<ref name=sja1>{{cite web|url=http://www.sja.org.uk/sja/about-us/our-history/industrial-revolution.aspx|title=St John Ambulance in the Industrial Revolution|publisher=St John Ambulance UK|access-date=2007-06-16|archive-url=https://web.archive.org/web/20070626032454/http://www.sja.org.uk/sja/about-us/our-history/industrial-revolution.aspx|archive-date=26 June 2007}}</ref> It was modelled on a military-style command and discipline structure.

===Motorization===
[[File:Royal Naval World War I ambulance truck, KT9793, c 1919 Wellcome L0034479.jpg|right|thumb|A [[Royal Navy]] ambulance during [[World War I]]]]
Also in the late 19th century, the [[automobile]] was being developed, and in addition to 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 motorized ambulance was brought into 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.<ref name=Ambulance/> This was followed in 1900 by New York City, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2&nbsp;hp motors on the rear axle.<ref name=Ambulance/>

During [[World War I]], further advances were made in providing care before and during transport; [[traction splint]]s were introduced during the war and were found to have a positive effect on the [[morbidity]] and [[death|mortality]] of patients with leg fractures.<ref>{{cite journal|pmid=15326449|year=2004|last1=Bledsoe|first1=B.|title=Traction splint. An EMS relic?|journal=Journal of Emergency Medical Services|volume=29|issue=8|pages=64–9|last2=Barnes|first2=D.}}</ref> [[Two-way radio]]s became available shortly after World War I, enabling for more efficient radio [[Dispatch (logistics)|dispatch]] of ambulances in some areas. Prior to [[World War II]], there were some areas where a modern ambulance carried advanced medical equipment, was staffed by a [[physician]], and was dispatched by radio. In many locations, however, ambulances were [[hearse]]s, the only available vehicle that could carry a recumbent patient, and were thus frequently run by [[funeral home]]s. These vehicles, which could serve either purpose, were known as [[combination car (ambulance)|combination car]]s.<ref name="Kuehl">Kuehl, Alexander E. (Ed.). ''Prehospital Systems and Medical Oversight'', 3rd edition. ''National Association of EMS Physicians''. 2002.{{page needed|date=November 2018}}</ref><ref>{{Cite web|title=Miller-Meteor History|url=http://www.miller-meteor.com/history.asp|archive-url=https://web.archive.org/web/20070314002150/http://www.miller-meteor.com/history.asp|archive-date=14 March 2007|access-date=23 February 2007|website=Miller-Meteor}}</ref>

Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.{{citation needed|date=June 2020}}

===Rise of modern EMS===
[[File:DFVAC 1970s Cadillac Miller Meteor color.jpg|right|thumb|A 1973 [[Cadillac]] [[Miller-Meteor#Miller-Meteor|Miller-Meteor]] ambulance. Note the raised roof, with more room for the attendants and patients.]]
Advances in the 1960s, especially the development of [[Cardiopulmonary resuscitation|CPR]] and [[defibrillation]] as the standard form of care for out-of-hospital [[cardiac arrest]], along with new [[pharmaceutical]]s, led to changes in the tasks of the ambulances.<ref>{{cite journal|vauthors=Kouwenhoven WB, Jude JR, Knickerbocker GG|title=Closed-chest cardiac massage|journal=JAMA|volume=173|issue=10|pages=1064–67|date=July 1960|pmid=14411374|doi=10.1001/jama.1960.03020280004002|s2cid=2663379|url=http://cdm15290.contentdm.oclc.org/u?/p15290coll5,3643|url-access=subscription}}{{Dead link|date=January 2021 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> In [[Belfast]], Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. [[Freedom House Ambulance Service]] was the first civilian emergency medical service in the United States to be staffed by [[paramedics]], all of whom were African-American.

One well-known report in the US during that time was ''[[Accidental Death and Disability: The Neglected Disease of Modern Society]]'', also known as ''The White Paper''. The report concluded that ambulance services in the US varied widely in quality and were often unregulated and unsatisfactory.<ref>{{Cite book|url=http://www.nap.edu/openbook.php?record_id=9978&page=R1|title=Accidental Death and Disability: The Neglected Disease of Modern Society|year=1966|doi=10.17226/9978|pmid=25057729|isbn=978-0-309-07532-9|access-date=2011-09-17|author1=National Academy of Sciences (US) National Research Council (US) Committee on Trauma|author2=National Academy of Sciences (US) National Research Council (US) Committee on Shock}}</ref> These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. The government reports resulted in the creation of [[Standardization|standard]]s in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.

In 1971 a progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a "superb white paper" that "jolted and wakened the entire structure of organized medicine." This report is created as a "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services". Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting.<ref>{{cite journal|doi=10.1097/00005373-197103000-00001|pmid=5545943|title='Accidental death and disability: the neglected disease of modern society'. A progress report|journal=The Journal of Trauma: Injury, Infection, and Critical Care|volume=11|issue=3|pages=195–206|year=1971|last1=Gaston|first1=Sawnie R.}}</ref> Such advancements included Dr. [[R Adams Cowley]] creating the country's first statewide EMS program, in [[Maryland]].<ref>{{cite web|url=http://www.umm.edu/shocktrauma/history.html|title=History|publisher=Umm.edu|access-date=2012-04-05|archive-url=https://web.archive.org/web/20051224082924/http://www.umm.edu/shocktrauma/history.html|archive-date=24 December 2005}}</ref>

The developments were paralleled in other countries. In the United Kingdom, a 1973 law merged the municipal ambulance services into larger agencies and set national standards.<ref name="HMSO">{{cite web|title=Royal Commission on the National Health Service|url=http://www.sochealth.co.uk/national-health-service/royal-commission-on-the-national-health-service-contents/royal-commission-on-the-nhs-chapter-15/|website=Socialist Health Association|publisher=HMSO|access-date=12 June 2015|url-status=live|archive-url=https://web.archive.org/web/20150521155911/http://www.sochealth.co.uk/national-health-service/royal-commission-on-the-national-health-service-contents/royal-commission-on-the-nhs-chapter-15/|archive-date=21 May 2015|date=1979-07-17}}</ref> In France, the first official [[Emergency medical services in France|SAMU agencies]] were founded in the 1970s.<ref name="Barrier">{{cite book|author=Geneviève Barrier|title=La vie entre les mains|editor=Odile Jacob|date=1992|page=141|language=fr}}</ref>

==Organization==
Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization. This variation may lead to large differences in levels of care and expected scope of practice. Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.

===Municipal "third service" ambulance service===
[[File:An ambulance in Kiev.jpg|thumb|A government-owned ambulance in [[Kyiv]], Ukraine]]
Operating separately from (although alongside) the fire and police services of the area, these ambulances are funded by local, provincial or national governments. In some countries, these only tend to be found in big cities, whereas in countries such as the United Kingdom, almost all emergency ambulances are part of a national health system.<ref>{{cite web|title=UK NHS Ambulance Service Information|url=http://www.nhs.uk/nhsengland/aboutnhsservices/emergencyandurgentcareservices/pages/ambulanceservices.aspx|url-status=deviated|archive-url=https://web.archive.org/web/20091106000344/http://www.nhs.uk/nhsengland/aboutnhsservices/emergencyandurgentcareservices/pages/ambulanceservices.aspx|archive-date=2009-11-06|access-date=2009-11-01|publisher=NHS Direct}}</ref>

In the United States, ambulance services provided by a local government are often referred to as "third service" EMS (the fire department, police department, and EMS department forming an emergency services trio) by the members of said service, as well as other city officials and residents. The most notable examples of this model in the United States are [[Pittsburgh Bureau of Emergency Medical Services]], [[Boston Emergency Medical Services|Boston EMS]], [[New Orleans Emergency Medical Services]], and [[Cleveland EMS]]. Government ambulance services also have to take civil service exams just like government fire departments and police. In the United States, certain federal government agencies employ emergency medical technicians at the basic and advanced life support levels, such as the [[National Park Service]] and the [[Federal Bureau of Prisons]].

===Fire- or police-linked service===
[[File:Ambulance 18 responds to emergency - DCFEMS - 2013-08-24.jpg|thumb|An ambulance of the [[District of Columbia Fire and Emergency Medical Services Department]] leaving a [[fire station]]]]
In countries such as the United States, Japan, France, South Korea and parts of India, ambulances can be operated by the local fire or police services. Fire-based EMS is the most common model in the United States, where nearly all urban fire departments provide EMS<ref>{{Cite web|title=IAFC Position: Fire-based Emergency Medical Services|url=http://www.iafc.org/IAFC-position-Fire-based-Emergency-Medical-Services|archive-url=https://web.archive.org/web/20160618191417/http://www.iafc.org/IAFC-position-Fire-based-Emergency-Medical-Services|archive-date=18 June 2016|access-date=27 May 2016}}</ref> and a majority of emergency transport ambulance services in large cities are part of fire departments. Examples of this model are the [[New York City Fire Department|New York City Fire Department (FDNY)]] and the [[Baltimore City Fire Department]].

It is rare for a police department in the United States to provide EMS or ambulance services, although many police officers have basic medical training (such as [[Naloxone|Nalaxone]] use and [[Cardiopulmonary resuscitation|CPR]]). One notable example is [[New Orleans Emergency Medical Services]], which was formed as a hospital-based service, was operated by the [[New Orleans Police Department]] from 1947 to 1985, and is currently operated by the New Orleans Health Department and the New Orleans Office of Homeland Security and Emergency Preparedness, separate from the [[New Orleans Fire Department]].

===Charity/not-for-profit ambulance service===
[[File:Modena ambulance.jpg|thumb|A volunteer ambulance crew in [[Modena]], Italy]]
Charities or non-profit ambulance departments operate some emergency medical services. They are primarily staffed by [[Volunteering|volunteers]], though many also have paid personnel. These may be linked to a volunteer fire service, and some volunteers may provide both services. Some ambulance charities specialize in providing cover at public gatherings and events (e.g. sporting events), while others provide care to the wider community.

The [[International Red Cross and Red Crescent Movement]] is the largest charity in the world that provides emergency medicine.<ref name="SJA2"/> (in some countries, it operates as a private ambulance service). Other organisations include [[St John Ambulance]],<ref name=SJA2>{{cite web|url=http://www.redcross.org.uk/en/What-we-do/First-aid/Event-first-aid-and-ambulance-support/Ambulance-service-support|title=BritishRedCross Ambulance Support|publisher=British Red Cross|access-date=2017-07-02|archive-date=10 October 2017|archive-url=https://web.archive.org/web/20171010095954/http://www.redcross.org.uk/en/What-we-do/First-aid/Event-first-aid-and-ambulance-support/Ambulance-service-support}}</ref><ref name="HK">{{Cite journal |last1=Leung |first1=Lancelot Hei Lok |last2=Kwok |first2=Anthony Yunda |last3=Wong |first3=Eponine Kate |last4=Cheung |first4=Arthur Chi Kin |last5=Rainer |first5=Timothy Hudson |date=2025 |title=The Hong Kong emergency medical services system: A scoping review |journal=Hong Kong Journal of Emergency Medicine |language=en |volume=32 |issue=4 |article-number=e70025 |doi=10.1002/hkj2.70025 |issn=2309-5407|doi-access=free }}</ref> the [[Order of Malta Ambulance Corps]] and [[Hatzalah]],<ref>{{cite web|url=http://195.218.114.18/orderofmalta/global/site/what-we-do.asp?id=15|title=Order of Malta Ambulance Corps|access-date=2007-06-02|publisher=Order of Malta Ambulance Corps|archive-url=https://web.archive.org/web/20071009185426/http://195.218.114.18/orderofmalta/global/site/what-we-do.asp?id=15|archive-date=9 October 2007}}</ref> as well as small local volunteer/paid departments. In the United States, volunteer ambulances are rarer, but can still be seen in both metropolitan and rural areas (e.g. [[Hatzalah]]). Charities such as [[BASICS Scotland]], specialise in facilitating training medical professionals to volunteer to assist the statutory ambulance services in the care of patients, through their attendance at those with serious illnesses or injuries.

A few charities provide ambulances for taking patients on trips or vacations away from hospitals, hospices or care homes where they are in long-term care. Examples include the UK's [[Jumbulance]] project.<ref name=jumbulance>{{cite web|url=http://www.jumbulance.org.uk/faq.html|title=Questions and Answers|access-date=2007-06-02|publisher=Jumbulance Travel Trust|archive-url=https://web.archive.org/web/20070702165512/http://www.jumbulance.org.uk/faq.html|archive-date=2 July 2007}}</ref>

===Private/corporate ambulance service===
[[File:American Medical Response6.jpg|thumb|[[American Medical Response]] ambulances staging in [[Tallahassee, Florida]] during [[Hurricane Irma]]]]
Some ambulances are operated by commercial companies with paid employees, usually on a contract to the local or national government, Hospital Networks, Health Care Facilities and Insurance Companies.

In the U.S., private ambulance companies provide emergency medical services in large cities and rural areas by contracting with local governments. In areas where the local county or city provide their own emergency services, private companies provide discharges and transfers from hospitals and to/from other health related facilities and homes. In most areas private companies are part of the local government emergency disaster plan, and are relied upon for the overall EMS response, treatment and recovery.

In some areas, private companies may provide only the patient transport elements of ambulance care (i.e. non-urgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility-impaired if they have for example fallen and simply need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available at all times for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events.<ref>{{cite web|url=http://www.firstaidservices.net.au|title=First Aid Services|access-date=2009-03-31|publisher=First Aid Services|archive-url=https://web.archive.org/web/20081022023607/http://firstaidservices.net.au/|archive-date=22 October 2008}}</ref> In Latin America, private ambulance companies are often the only readily-available EMS service.{{Citation needed|date=May 2025}}

===Combined emergency service===
These are full service emergency service agencies, which may be found in places such as airports or large colleges and universities like for example the [[UCLA EMS]].Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where demand or budget is too low to support separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.

===Hospital-based service===
[[File:OgawaRedCross-Ambulance.jpg|thumb|An ambulance belonging to the Ogawa Red Cross Hospital in [[Ogawa, Saitama]], Japan]]
Hospitals or larger hospital systems may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Many hospital-based EMS departments operate solely with their hospital, though some operate more independently and can transport patients to whichever hospital may be needed or desired.

===Internal ambulances===
Many large factories and other industrial centers, such as [[chemical plant]]s, [[oil refineries]], [[breweries]], and [[distilleries]], have emergency medical 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.

==<span id="Purpose"></span>Purpose==
[[File:Star of life parts.svg|thumb|Six points on the Star of Life]]
Emergency medical services exists to fulfill the basic principles of [[first aid]], which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in [[medicine]] is demonstrated by the "star of life". The [[Star of Life]] shown here, where each of the 'arms' to the star represent one of the six points, are used to represent the six stages of high quality pre-hospital care, which are:<ref name="emscom">{{cite web|title=Design, Origin and Meaning of the Star of Life|url=http://www.ems.gov/vgn-ext-templating/ems/sol/pages/DesignOrigin.htm|url-status=deviated|archive-url=https://web.archive.org/web/20081015063458/https://www.ems.gov/vgn-ext-templating/ems/sol/pages/DesignOrigin.htm|archive-date=2008-10-15|access-date=2008-08-09|publisher=NHTSA}}</ref>

#'''Early detection''' &ndash; members of the public, or another agency, find the incident and understand the problem
# '''Early reporting''' &ndash; the first persons on scene make a call to the emergency medical services (911) and provide details to enable a response to be mounted
# '''Early response''' &ndash; the first professional (EMS) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin
# '''Good on-scene/field care''' &ndash; the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.
# '''Care in transit '''-&ndash; the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
# '''Transfer to definitive care''' &ndash; the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

==<span id="Delivery"></span>Strategies for delivering care==
[[File:Haige esmavaatlus kopteril.jpg|thumb|Training for EMS in [[Estonia]].]]

Although a variety of differing [[Philosophy of Medicine|philosophical]] approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one [[physician]]-led and the other led by pre-hospital allied health staff such as [[emergency medical technician]]s or [[paramedic]]s. These models are commonly referred to as the '''Franco-German model''' and '''Anglo-American model'''.<ref name="WF">{{cite journal|author=Dick WF|title=Anglo-American vs. Franco-German emergency medical services system|journal=Prehospital and Disaster Medicine|volume=18|issue=1|pages=29–35; discussion 35–7|year=2003|pmid=14694898|doi=10.1017/s1049023x00000650|s2cid=31020961}}</ref><ref name="Al-Shaqsi">{{cite journal|author=Sultan Al-Shaqsi|title=Models of International Emergency Medical Service (EMS) Systems|journal=Oman Medical Journal|volume=25|issue=4|pages=320–323|pmc=3191661|year=2010|pmid=22043368|doi=10.5001/omj.2010.92}}</ref>

Studies have been inconclusive as to whether one model delivers better results than the other.<ref name="WF"/><ref name="Al-Shaqsi"/><ref>{{cite journal|title=International comparison of prehospital trauma care systems|journal=Injury|volume=38|issue=9|pages=993–1000|year=2007|author=BS Roudsari|pmid=17640641|doi=10.1016/j.injury.2007.03.028}}</ref> A 2010 study in the [[Oman Medical Journal]] suggested that rapid transport was a better strategy for trauma cases, while stabilization at the scene was a better strategy for cardiac arrests.<ref name="Al-Shaqsi"/>

===<span id="Levels"></span>Levels of care===
[[File:Bags of medical supplies and defibrillators.jpg|thumb|Bags of medical supplies and [[defibrillators]] at the [[York Region EMS]] Logistics Headquarters in [[Ontario]], Canada]]
Many systems have tiers of response for medical emergencies. For example, a common arrangement in the United States is that fire engines or volunteers are sent to provide a rapid initial response to a medical emergency, while an ambulance is sent to provide advanced treatment and transport the patient. In France, fire service and private company ambulances provide basic care, while hospital-based ambulances with physicians on board provide advanced care. In many countries, an [[Air medical services|air ambulance]] provides a higher level of care than a regular ambulance.

Examples of level of care include:
*[[First aid]] consists of basic skills that are commonly taught to members of the public, such as [[cardiopulmonary resuscitation]], bandaging wounds and saving someone from [[choking]].
*[[Basic Life Support]] (BLS) is often the lowest level of training that can be held by those who treat patients on an ambulance.<ref>{{Cite book|last=Ventura|first=Christian|title=The Emergency Medical Responder: Training and Succeeding as an EMT/EMR|publisher=Springer International Publishing|isbn=978-3-030-64395-9|chapter=1: The EMS System|date=20 January 2021}}</ref> Commonly, it includes administering [[oxygen therapy]], some drugs and a few invasive treatments. BLS personnel may either operate a BLS ambulance on their own, or assist a higher qualified crewmate on an ALS ambulance. In English-speaking countries, BLS ambulance crew members are known as [[emergency medical technician]]s, [[emergency care assistant]]s or [[Primary care paramedic]]s in [[Canada]].
*[[Intermediate Life Support]] (ILS), also known as Limited Advanced Life Support (LALS), is positioned between BLS and ALS but is less common than both. It is commonly a BLS provider with a moderately expanded skill set (such as an [[AEMT]], but where it is present it usually replaces BLS.
*[[Advanced Life Support]] (ALS) has a considerably expanded range of skills such as [[intravenous therapy]], [[endotracheal intubation]], [[cricothyrotomy]] and interpretation of [[electrocardiogram]]s. The scope of this higher tier response varies considerably by country. [[Paramedic]]s commonly provide ALS, but some countries require it to be a higher level of care and instead employ [[physician]]s in this role. Additionally Advanced Life Support includes administering therapeutic doses of electrical shock to those who are in cardiac arrest or using drugs to stimulate the heart, Airway therapy, and so on and so forth. Most ambulances are equipped with advanced Life Support equipment and have paramedics on board. While some fire departments have ambulances, first aid and squads utilize ambulances for emergency medical services.
*Critical Care Transport (CCT or CCP), also known as medical retrieval or rendez vous MICU protocol in some countries (Australia, NZ, Great Britain, and Francophone Canada) refers to the critical care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in regionalized systems of hospital care where intensive care services are centralized to a few specialist hospitals. An example of this is the [[Emergency Medical Retrieval Service]] in Scotland. This level of care is likely to involve traditional healthcare professionals (in addition to or instead of critical care-trained paramedics), meaning [[nurses]] and/or physicians working in the pre-hospital setting and even on ambulances.

===Transport-only===
[[File:ERanger-Sudan09.JPG|thumb|right|200px|A [[motorcycle ambulance]] in [[South Sudan]]]]
The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was historically the case in all countries. It remains the case in much of the developing world, where operators as diverse as taxi drivers<ref name=motorbike/> and undertakers may transport people to hospital.

===Transport-centered EMS===
[[File:BFDandUVES.JPG|thumb|Ambulances parked outside an emergency room in [[Binghamton, New York]]]]
The Anglo-American model is also known as "load and go" or "scoop and run".<ref name="Al-Shaqsi"/> In this model, ambulances are staffed by [[paramedic]]s and/or [[emergency medical technician]]s. They have specialized medical training, but not to the same level as a physician. In this model it is rare to find a physician actually working routinely in ambulances, although they may be deployed to major or complex cases. The physicians who work in EMS provide [[Regulation|oversight]] for the work of the ambulance crews. This may include off-line medical control, where they devise [[Medical guideline|protocols]] or 'standing orders' (procedures for treatment). This may also include on-line medical control, in which the physician is contacted via radio or phone to provide advice and authorization for various medical interventions or for a patient's desire to refuse care.

In some cases, such as in the UK, South Africa and Australia, a [[paramedic]] may be an autonomous medical professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient.<ref>{{cite news|url=http://news.bbc.co.uk/1/hi/health/4634569.stm|title=What Does a Super Paramedic Do? (BBC News website)|access-date=2008-09-19|date=30 June 2005}}</ref> Recently "Telemedicine" has been making an appearance in ambulances. Similar to online medical control, this practice allows paramedics to remotely transmit data such as vital signs and 12 and 15 lead ECGs to the hospital from the field. This allows the emergency department to prepare to treat patients prior to their arrival.<ref>{{Cite book|title=Foundations of EMS systems|last=J.|first=Walz, Bruce|others=Zigmont, Jason J.|isbn=978-1-284-04178-1|edition=Third|location=Burlington, Massachusetts|oclc=954134197|date=2016-09-02}}</ref> This is allowing lower level providers (Such as EMT-B) in the United States to utilize these advanced technologies and have the doctor interpret them, thus bringing rapid identification of rhythms to areas where paramedics are stretched thin.<ref>{{Cite web|url=https://portal.ct.gov/-/media/departments-and-agencies/dph/dph/ems/pdf/statewide_protocols/connecticutstatewideemsprotocolsv20172final20171012.pdf?la=en|title=CT Statewide EMS Protocols 2017.2|last=CT DPH and OEMS}}</ref> While most insurance companies only reimburse EMS providers for transporting patients to 911 receiving facilities (e.g. [[Emergency department|Emergency Departments]]),the [[Centers for Medicare & Medicaid Services|Center to Medicare and Medicaid Services]] is in the process of evaluating a payment model to enable reimbursement for patients evaluated and treated on-scene.<ref>{{Cite web|title=Emergency Triage, Treat, and Transport (ET3) Model {{!}} CMS Innovation Center|url=https://innovation.cms.gov/innovation-models/et3|access-date=2021-10-04|website=innovation.cms.gov}}</ref>

====Major trauma====
The essential decision in prehospital care is whether the patient should be immediately taken to the [[hospital]], or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the [[MEDEVAC]] aeromedical evacuation [[helicopter]], whereas the "stay and play" is exemplified by the French and Belgian [[SMUR emergency mobile resuscitation unit]] or the German "Notarzt"-System (preclinical emergency physician).

The strategy developed for prehospital trauma care in North America is based on the [[Golden Hour (medicine)|Golden Hour]] theory, i.e., that a trauma victim's best chance for survival is in an [[operating room]], with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal [[bleeding]], especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure {{not a typo|''a''irway}}, {{not a typo|''b''reathing}} and {{not a typo|''c''irculation}}; external bleeding control; [[intubation|endotracheal intubation]]) and the victim is transported as fast as possible to a [[trauma centre]].<ref>Accidental Death and Disability: The Neglected Disease of Modern Society, (1966), National Academy of Sciences (White Paper)</ref>

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with [[Physical trauma|trauma]], rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation [[myocardial infarctions]] ([[STEMI]]) occurring outside of the hospital, or even inside community hospitals without their own [[Percutaneous coronary intervention|PCI]] labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the [[door to balloon]] time. The longer the time interval, the greater the damage to the [[myocardium]], and the poorer the long-term prognosis for the patient.<ref>{{cite journal|vauthors=Nallamothu BK, Bates ER|title=Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything?|journal=The American Journal of Cardiology|volume=92|issue=7|pages=824–6|date=October 2003|pmid=14516884|doi=10.1016/S0002-9149(03)00891-9}}</ref> Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab.<ref>{{cite journal|vauthors=Bogaty P, Buller CE, Dorian P, O'Neill BJ, Armstrong PW|title=Applying the new STEMI guidelines: 1. Reperfusion in acute ST-segment elevation myocardial infarction|journal=CMAJ|volume=171|issue=9|pages=1039–41|date=October 2004|pmid=15505262|pmc=526323|doi=10.1503/cmaj.1041417}}</ref> The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent.<ref>{{cite web|url=http://www.ottawaheart.ca/heart_disease/heart_attack.htm|title=UOHI – Heart Attack|publisher=Ottawaheart.ca|access-date=2010-07-29|archive-date=1 May 2015|archive-url=https://web.archive.org/web/20150501122326/http://www.ottawaheart.ca/heart_disease/heart_attack.htm}}</ref> In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.<ref>{{cite journal|vauthors=Cantor WJ, Morrison LJ|title=Guidelines for STEMI|journal=CMAJ|volume=172|issue=11|pages=1425; author reply 1426|date=May 2005|pmid=15911845|pmc=557963|doi=10.1503/cmaj.1041728}}</ref>

===Physician-led EMS===
[[File:Rallye Rejvíz 2012, ZZS ZK, VW T5 Strobel (01).jpg|thumb|right|Ambulance in the [[Czech Republic]]]]
Physician-led EMS is also known as the Franco-German model, "stay and play", "stay and stabilize" or "delay and treat".<ref name="Al-Shaqsi"/> In a physician-led system, doctors respond directly to all major emergencies requiring more than simple [[first aid]]. The physicians will attempt to treat casualties at the scene and will only transport them to hospital if it is deemed necessary. If patients are transported to hospital, they are more likely to go straight to a ward rather than to an [[emergency department]].<ref name="Al-Shaqsi"/> Countries that use this model include Austria, France, Belgium, Luxembourg, Italy, Spain, Brazil and Chile.

In some cases in this model, such as France, there is no direct equivalent to a paramedic.<ref>{{cite web|url=http://www.samu-de-france.fr/en/news/front/afficher/rescue_services_in_europe_france-ref/?id_actu=170|title=SAMU de France website|access-date=2008-09-19|archive-url=https://web.archive.org/web/20081114192458/http://www.samu-de-france.fr/en/news/front/afficher/rescue_services_in_europe_france-ref/?id_actu=170|archive-date=14 November 2008}}</ref> Physicians and (in some cases) [[nurses]] provide all medical interventions for the patient. Other ambulance personnel are not non-medically trained and only provide driving and heavy lifting. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is an assistant to the physician with a restricted [[scope of practice]]. They are only permitted to perform [[Advanced Life Support]] (ALS) procedures if authorized by the physician, or in cases of immediate life-threatening conditions.<ref name=g1/> [[Ambulances]] in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.

==<span id="Personnel"></span>Personnel==
[[File:Woman collapses in the East Village of New York.jpg|thumb|EMT staff at an emergency call in [[New York City]]]]
[[File:MS1 on stretcher.jpg|thumb|A patient arriving at a hospital]]

Ambulance personnel are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.<ref>{{Cite web|title=EMTs and Paramedics : Occupational Outlook Handbook:: U.S. Bureau of Labor Statistics|url=https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm#tab-3|access-date=2023-05-10|website=bls.gov|language=en-us}}</ref>

A unique aspect of EMS is that there are two hierarchies of authority, as the [[command hierarchy|chain of command]] is separate to medical authority.<ref>{{cite magazine|url=https://www.fireengineering.com/1998/09/01/228424/fire-ems-merger-an-examination-of-cultural-differences/#gref|date=1998-09-01|access-date=2019-02-15|title=Fire/EMS Merger: An Examination of Cultural Differences|magazine=[[Fire Engineering (magazine)|Fire Engineering]]|archive-date=29 August 2018|archive-url=https://web.archive.org/web/20180829175240/https://www.fireengineering.com/articles/print/volume-151/issue-9/features/fire-ems-merger-an-examination-of-cultural-differences.html#gref}}</ref>

===Basic life support (BLS)===

====Emergency medical dispatcher====
An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast [[Emergency service#Response time|response time]] by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

====First responder====
{{See also|Certified first responder}}
Certified first responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, [[cardio-pulmonary resuscitation]] (CPR), and [[automated external defibrillator]] (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an [[emergency call]]. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before the ambulance arrives, and to then assist the ambulance crew.<ref>{{Cite web|url=http://medical-dictionary.thefreedictionary.com/first+responder|title=Free Dictionary}}</ref>

Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include [[Community First Responder]] schemes run by ambulance services the UK and [[Certified First Responder in France|similar volunteer schemes]] operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as [[rescue squad]]s. [[Police officer]]s and [[firefighter]]s who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level.

Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The [[International Red Cross and Red Crescent Movement]] and [[St John Ambulance]] both provide first aiders in these roles.

====Ambulance driver====
Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid and CPR certificates), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.<ref>{{cite web|url=http://www.unionems.com/categories_vol_membership.htm|title=Union EMS|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080929213547/http://www.unionems.com/categories_vol_membership.htm|archive-date=29 September 2008}}</ref>

====Non-emergency attendant====
Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an [[Automated external defibrillator|AED]], oxygen therapy, pain relief and other live-saving or [[palliative]] skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom.<ref>{{cite web|url=http://www.nhscareers.nhs.uk/details/Default.aspx?Id=907/|title=NHS Careers|access-date=2008-08-20|archive-date=21 May 2020|archive-url=https://web.archive.org/web/20200521233658/https://www.healthcareers.nhs.uk/}}</ref><ref>{{cite web|url=http://www.health-care-jobs.co.uk/index/index.php?item_id=107|title=ACA job description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20090211102913/http://www.health-care-jobs.co.uk/index/index.php?item_id=107|archive-date=11 February 2009}}</ref>

====Emergency care assistant====
[[Emergency care assistant]]s are of a frontline under both emergency and non-emergency conditions to incidents. Their role is to assist the clinician that they are working with, either a Technician or Paramedic, in their duties, whether that be drawing up drugs, setting up fluids (but not attaching), doing basic observations or performing 12 lead ECG assessments.

====Emergency medical technician====
[[File:EMTs loading a patient.jpg|thumb|right|EMTs loading a patient into an ambulance]]
[[Emergency medical technician]]s are usually able to perform a wide range of emergency care skills, such as automated [[defibrillation]], care of spinal injuries and [[oxygen therapy]].<ref>{{cite web|url=http://stats.bls.gov/oco/oco2001.htm#training|title=Dept. of Labor EMT Job Description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080725011655/http://www.stats.bls.gov/oco/oco2001.htm#training|archive-date=25 July 2008}}</ref><ref>{{cite web|url=http://www.health.state.ny.us/nysdoh/ems/pdf/srgemt.pdf|title=NYS EMT-B Job Description|access-date=2008-08-20}}</ref> In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs (including but not limited to Epinephrine, Narcan, Oxygen, Aspirin, Nitroglycerin – dependent on country, state, and medical direction), more advanced airway procedures, CPAP, and limited cardiac monitoring.<ref>{{cite web|url=http://www.medicalalertsystemsnews.com/EMS%20Scope%20of%20Practice2006.pdf|title=North Dakota EMT-B Scope of Practice|access-date=2008-08-20|archive-url=https://web.archive.org/web/20160303220257/http://www.medicalalertsystemsnews.com/EMS%20Scope%20of%20Practice2006.pdf|archive-date=3 March 2016}}</ref> Most advanced procedures and skills are not within the national scope of practice for an EMT.<ref>{{cite web|url=http://www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pdf|archive-url=https://web.archive.org/web/19980529212433/http://www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pdf|archive-date=29 May 1998|title=NHTSA EMT-B Scope of Practice|access-date=2008-08-20}}</ref> As such most states require additional training and certifications to perform above the national curriculum standards.<ref>{{cite web|url=http://www.health.state.nd.us/EMS/pdfs/EMS%20Provider%20Skill%20Sets/EMS%20Skills%20for%20providers%202008EMTB.pdf|title=EMT-B additional skills|access-date=2008-08-20}}</ref><ref>{{cite web|url=http://www.healthoneems.com/course_pdf/2008/IV_Student_Application_Packet.pdf|title=Colorado EMT-B IV Certification|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080824013231/http://www.healthoneems.com/course_pdf/2008/IV_Student_Application_Packet.pdf|archive-date=24 August 2008}}</ref> In the United States, an EMT certification requires intense courses and training in field skills.  Certifications are state-specific and last varying durations, though [[National Registry of Emergency Medical Technicians|National Registry]] certification simplifies the reciprocity process in many states. The National Registry of Emergency Medical Technicians renamed the certification levels for EMS professionals as follows: Emergency Medical Responder (NREMR), Emergency Medical Technician (NREMT), Advanced EMT (NRAEMT), and Paramedic (NRP).<ref>{{Cite web |title=EMS Recertification Guide · Completing Recertification {{!}} National Registry of Emergency Medical Technicians |url=https://nremt.org/ |access-date=2025-11-11 |website=nremt.org}}</ref>

===Advanced life support (ALS)===

====Paramedic====
[[File:Cervical Collar Emergency.jpg|thumb|A girl treated by a paramedic]]
A [[paramedic]] has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including [[Intravenous therapy|cannulation]] (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform [[endotracheal intubation]]), [[cardiac monitoring]], 12-lead ECG interpretation, [[ultrasound]], [[intubation]], pericardiocentesis, cardioversion, [[thoracostomy]], and other skills such as performing a surgical [[cricothyrotomy]].<ref>{{cite web|url=http://www.prospects.ac.uk/cms/ShowPage/Home_page/Explore_types_of_jobs/Types_of_Job/p!eipaL?state=showocc&pageno=1&idno=205|title=Paramedic: Job description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20090202161146/http://www.prospects.ac.uk/cms/ShowPage/Home_page/Explore_types_of_jobs/Types_of_Job/p!eipaL?state=showocc&idno=205&pageno=1|archive-date=2 February 2009}}</ref> The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment.<ref>Editors of Salem Press (2008). Paramedics. Magill's Medical Guide, 4th Rev. ed.. Salem Press. Retrieved from http://elibrary.bigchalk.com {{Webarchive|url=https://web.archive.org/web/20200527092602/https://explore.proquest.com// |date=27 May 2020 }}</ref> In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution.<ref>{{cite web|url=http://www.hpc-uk.org/aboutregistration/protectedtitles/|title=HPC – Health Professions Council – Protected titles|access-date=2008-08-20|archive-url=https://web.archive.org/web/20181107140106/http://www.hpc-uk.org/aboutregistration/protectedtitles/|archive-date=7 November 2018}}</ref> In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care,<ref>{{cite journal|vauthors=Schmidt TA, Federiuk CS, Zechnich A, Forsythe M, Christie M, Andrews C|title=Advanced life support in the wilderness: 5-year experience of the Reach and Treat team|journal=Wilderness & Environmental Medicine|volume=7|issue=3|pages=208–15|date=August 1996|pmid=11990115|doi=10.1580/1080-6032(1996)007[0208:ALSITW]2.3.CO;2|doi-access=free}}</ref> Flight Paramedic Certification ([[FP-C]]),<ref>{{cite web|url=http://www.flightparamedic.org/|title=Flight Paramedic Certification|access-date=2008-08-20|archive-date=19 July 2012|archive-url=https://web.archive.org/web/20120719110810/http://www.flightparamedic.org/}}</ref> and Critical Care Emergency Medical Transport Program certification.<ref name=CCEMTP>{{cite web|url=http://ehs.umbc.edu/CE/CCEMT-P/|title=CCEMTP|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080621174320/http://ehs.umbc.edu/CE/CCEMT-P/|archive-date=21 June 2008}}</ref>

====Critical care paramedic====
[[File:Toronto Paramedic Services Critical Care Transport ambulance.jpg|thumb|A [[Toronto Paramedic Services]] Critical Care ambulance]]
A critical care paramedic, also known as an advanced practice paramedic or specialist paramedic, is a paramedic with additional training to deal with critically ill patients.<ref name=CCEMTP/><ref>{{Cite thesis|last1=Paquette|first1=Anthony John|title=The Feasibility of the Advanced Practice Paramedic|type=MPH thesis|publisher=University of Connecticut|year=2005|url=https://opencommons.uconn.edu/uchcgs_masters/78}}</ref><ref>{{cite web|title=Critical Care Paramedic Position Paper|url=http://www.flightparamedic.org/documents/CriticalCareParamedicPositionPaper.pdf|publisher=International Association of Flight Paramedics|access-date=29 September 2011|archive-url=https://web.archive.org/web/20120111064235/http://www.flightparamedic.org/documents/CriticalCareParamedicPositionPaper.pdf|archive-date=11 January 2012}}</ref> Critical care paramedics often work on [[Air medical services|air ambulances]], which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances.<ref name="bcctpc"/> The training, permitted skills, and certification requirements vary from one jurisdiction to the next. It also varies to whether they are trained externally by a university or professional body<ref name="bcctpc">{{cite web|title=Report of a National Study of the Certified Critical Care Paramedic|url=http://www.bcctpc.org/Documents/Ground%20Critical%20Care%20Summary%20Blueprint.pdf|publisher=The Board for Critical Care Transport Certification|access-date=29 September 2011|archive-url=https://web.archive.org/web/20120119104656/http://www.bcctpc.org/Documents/Ground%20Critical%20Care%20Summary%20Blueprint.pdf|archive-date=19 January 2012}}</ref><ref>{{cite web|title=Board of Critical Care Transport Paramedic|url=http://www.bcctpc.org/|publisher=The Board for Critical Care Transport Certification|access-date=29 September 2011}}</ref><ref>{{cite web|title=CCEMTP Course|url=http://ehs.umbc.edu/CE/CCEMT-P/|publisher=University of Maryland Baltimore County|access-date=11 August 2011|archive-url=https://web.archive.org/web/20110811164911/http://ehs.umbc.edu/CE/CCEMT-P/|archive-date=11 August 2011}}</ref><ref>{{cite web|url=http://www.emsacademy.us/Education/CriticalCareEducation/CertifiedIntensiveCareProvider/tabid/1962/Default.aspx|title=Cleveland Clinic CICP program|access-date=29 September 2011|archive-url=https://web.archive.org/web/20110822013843/http://www.emsacademy.us/Education/CriticalCareEducation/CertifiedIntensiveCareProvider/tabid/1962/Default.aspx|archive-date=22 August 2011}}</ref> or 'in house' by their EMS agency.<ref>{{cite web|url=http://www.wakegov.com/ems/staff/app|title=Wake County EMS|access-date=29 September 2011|archive-date=8 August 2019|archive-url=https://web.archive.org/web/20190808140756/http://www.wakegov.com/ems/staff/app}}</ref><ref>{{cite web|url=http://www.medstar911.org/critical-care-transport|title=MedStar EMS|access-date=29 September 2011|archive-url=https://web.archive.org/web/20131020163723/http://www.medstar911.org/critical-care-transport|archive-date=20 October 2013}}</ref>

These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are [[dobutamine]], [[dopamine]], [[Propofol]], [[blood]] and [[blood products]] to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as [[Mechanical ventilation|mechanical ventilators]], [[Intra-aortic balloon pump]] (IABP) and external [[pacemaker]] monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs ([[Umbilical vein catheter|Umbilical Venous Catheter]]), UACs ([[Umbilical artery catheter|Umbilical Arterial Catheter]]), [[Cricothyrotomy|surgical airways]], [[Central venous catheter|central lines]], [[Arterial catheter|arterial lines]] and [[chest tube]]s.

====Emergency care practitioner====
In the United Kingdom and South Africa, some serving [[paramedic]]s receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications. An [[emergency care practitioner]] or paramedic practitioner is a position that is designed to bridge the link between ambulance care and the care of a [[general practitioner]]. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training,<ref>{{cite web|url=http://www.swast.nhs.uk/careersandvac/careers.htm#ECP|title=South Western Ambulance Service NHS Trust|access-date=2008-08-20|archive-url=https://web.archive.org/web/20070517154015/http://www.swast.nhs.uk/careersandvac/careers.htm#ECP|archive-date=17 May 2007}}</ref> and are authorized to perform specialized techniques. Additionally some may prescribe medicines for longer-term care, such as antibiotics and in the United Kingdom they can prescribe a broad range of medicines. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

===Traditional healthcare professionals in EMS===

====Registered nurses====
The use of [[registered nurses]] (RNs) in the pre-hospital setting is common in many countries in absence of paramedics. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed,<ref>{{cite journal|vauthors=Melby V, Ryan A|title=Caring for older people in prehospital emergency care: can nurses make a difference?|journal=Journal of Clinical Nursing|volume=14|issue=9|pages=1141–50|date=October 2005|pmid=16164532|doi=10.1111/j.1365-2702.2005.01222.x}}</ref> as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In [[Estonia]] 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the [[Netherlands]], all ambulances are staffed by a registered nurse with additional training in emergency nursing, anesthesia or critical care, and a driver-EMT.<ref>{{cite journal|author=Wulterkens D|title=EMS in the Netherlands: A Dutch Treat?|journal=Journal of Emergency Medical Services|date=6 December 2005|url=http://m.jems.com/article/operations-protcols/ems-netherlands-dutch-treat|access-date=15 May 2012|archive-url=https://web.archive.org/web/20150217201958/http://m.jems.com/article/operations-protcols/ems-netherlands-dutch-treat|archive-date=17 February 2015}}</ref> In [[Sweden]], since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs.<ref>{{cite journal|author=Suserud B|title=A new profession in the pre-hospital care field: the ambulance nurse|journal=Nursing in Critical Care|volume=10|issue=6|pages=269–71|year=2005|pmid=16255333|doi=10.1111/j.1362-1017.2005.00129.x|doi-access=free}}</ref><ref>{{cite journal|author=Bom A|title=International EMS system Design: Sweden|journal=Emsnews|date=Feb 2012|url=http://www.emsnews.com/read/featured-articles/international-ems-system-design-sweden|access-date=2012-08-29|archive-date=30 March 2014|archive-url=https://web.archive.org/web/20140330055643/http://www.emsnews.com/read/featured-articles/international-ems-system-design-sweden}}</ref> And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain.<ref>{{cite journal|url=https://www.boe.es/buscar/doc.php?id=BOE-A-2012-7655|title=Real Decreto 836/2012, de 25 de mayo, por el que se establecen las características técnicas, el equipamiento sanitario y la dotación de personal de los vehículos de transporte sanitario por carretera|trans-title=Royal Decree 836/2012, of 25 May, which establishes the technical characteristics, the sanitary equipment and the staffing of the vehicles of sanitary transport by road|language=es|journal=Boletín Oficial del Estado|volume=137|date=8 June 2012|pages=41589–41595}}</ref> In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols,<ref>{{cite web|url=http://www.interieur.gouv.fr/sections/a_l_interieur/defense_et_securite_civiles/sapeurs-pompiers/sdis/sssm/downloadFile/attachedFile_2/Protocoles.pdf?nocache=1143132331.45|title=Infermier Sapeur-Pompiers (French govt website)|language=fr|access-date=2012-08-29|archive-url=https://web.archive.org/web/20120306002244/http://www.interieur.gouv.fr/sections/a_l_interieur/defense_et_securite_civiles/sapeurs-pompiers/sdis/sssm/downloadFile/attachedFile_2/Protocoles.pdf?nocache=1143132331.45|archive-date=6 March 2012}}</ref> while SAMU-SMUR units are staffed by physicians and nurses<ref>{{cite web|url=http://www.samu06.org/en/smur.php?PHPSESSID=800aadc6593ea9bb266fac13beb29793|archive-url=https://archive.today/20130415211141/http://www.samu06.org/en/smur.php?PHPSESSID=800aadc6593ea9bb266fac13beb29793|archive-date=2013-04-15|title=The SMUR of Nice|access-date=2012-08-29}}</ref>
[[File:Prehospital RSI training.jpg|thumb|364x364px|Prehospital anaesthesia training]]

====Physician====
In countries with a [[physician]]-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a [[paramedic]], as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions.<ref name=g1>{{cite web|url=http://www.bundesaerztekammer.de/page.asp?his=0.7.47.3222|title=Bundesärztekammer – Notfall: Notkompetenz I (German Federal Board of Physicians: Directives regarding emergency powers for Paramedics)|publisher=Bundesaerztekammer.de|access-date=2010-07-29|language=de|archive-url=https://web.archive.org/web/20101120171646/http://bundesaerztekammer.de/page.asp?his=0.7.47.3222|archive-date=20 November 2010}}</ref>

In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the [[air ambulance]]s in the UK.<ref>{{cite web|url=http://www.londonsairambulance.com/|title=Londons Air Ambulance|access-date=2007-06-18|archive-url=https://web.archive.org/web/20080723121904/http://www.londonsairambulance.com/|archive-date=23 July 2008}}</ref><ref>{{cite web|url=http://www.surreyairambulance.co.uk/crew.asp/|title=Surrey Air Ambulance|access-date=2007-06-18|archive-url=https://web.archive.org/web/20171010101142/http://surreyairambulance.co.uk/crew.asp|archive-date=10 October 2017}}</ref> They may also provide advice and devise protocols for treatment, with a [[medical director]] acting as the most senior medical adviser to the ambulance service. In the United States, EMS became an officially recognized subspecialty by the American Board of Emergency Medicine in 2010, and the first examinations were held in 2013.<ref>{{Cite web|last=PA-C|first=Fred Wu, MHS|date=2010-10-05|title=EMS officially recognized as an EM subspecialty|url=https://www.aliem.com/ems-officially-recognized-as-em/|access-date=2022-08-14|website=ALiEM|language=en-US}}</ref> Many states now recommend EMS board certification for newly hired medical directors of EMS agencies.

==Specialist EMS==
===Air ambulances===
{{See also|Air medical services}}
[[File:STARS_BK117_helicopter_Exterior.jpg|thumb|right|A Canadian [[Shock Trauma Air Rescue Society|STARS]] helicopter ambulance. [[Air medical services|Air ambulances]] often have staff who are specially trained for dealing with [[major trauma]] cases.]]

Air ambulances (also known as [[Medical evacuation|medevac]]) often complement a land ambulance service. In some remote areas, they may even form the primary ambulance service. Like many innovations in EMS, medical aircraft were first used in the military. One of the first recorded aircraft rescues of a casualty was in 1917 in [[Turkey]], when a soldier in the [[Imperial Camel Corps|Camel Corps]] who had been shot in the ankle was flown to hospital in a [[de Havilland DH9]].<ref>{{cite journal|doi=10.1136/jramc-132-01-08|title=The First Recorded Aeromedical Evacuation in the British Army – the True Story|journal=Journal of the Royal Army Medical Corps|volume=132|pages=34–36|year=1986|last1=Dolev|first1=E.|issue=1|pmid=3517313|s2cid=25684014|doi-access=free}}</ref> In 1928, the first civilian air medical service was founded in [[Australia]] to provide healthcare to people living in remote parts of the [[Outback]]. This service became the [[Royal Flying Doctor Service]].<ref>[http://www.flyingdoctor.org.au/About-Us/Our-History/ "Royal Flying Doctor Service."] {{Webarchive|url=https://web.archive.org/web/20100504193350/http://www.flyingdoctor.org.au/About-Us/Our-History |date=2010-05-04 }} ''flyingdoctor.net.''  Retrieved: 4 December 2010.</ref> The use of helicopters was pioneered in the [[Korean War]], when time to reach a medical facility was reduced from 8 hours to 3 hours in [[World War II]], and again to 2 hours by the [[Vietnam War]].<ref>Kay, Marcia Hillary. "[http://www.aviationtoday.com/rw/commercial/eng/40-Years-Retrospective-Its-Been-a-Wild-Ride_14518.html 40 Years Retrospective: It's Been a Wild Ride]" ''Rotor & Wing'', August 2007. Accessed: 8 June 2014. {{webarchive |url=https://web.archive.org/web/20140608203922/http://www.aviationtoday.com/rw/commercial/eng/40-Years-Retrospective-Its-Been-a-Wild-Ride_14518.html |date=8 June 2014 }}.</ref>

Aircraft can travel faster and operate in a wider coverage area than a land ambulance. They have a particular advantage for [[major trauma]] injuries, especially when they occur in rural or isolated areas. The well-established theory of the [[golden hour (medicine)|golden hour]] suggests that major trauma patients should be transported as quickly as possible to a specialist [[trauma center]].<ref>{{cite book|author=American College of Surgeons|title=Atls, Advanced Trauma Life Support Program for Doctors|publisher=Amer College of Surgeons|year=2008|isbn=978-1-880696-31-6}}</ref><ref name=ITLS2018>{{cite book|last1=Campbell|first1=John|title=International Trauma Life Support for Emergency Care Providers|date=2018|publisher=Pearson|isbn=978-1292-17084-8|edition=8th Global|page=12}}</ref> Therefore, medical first responders in a helicopter can provide both a higher level of care at the scene, faster transport to a specialist hospital<ref name="pmid15928284">{{cite journal|vauthors=Branas CC, MacKenzie EJ, Williams JC, Schwab CW, Teter HM, Flanigan MC|title=Access to trauma centers in the United States.|journal=JAMA|year=2005|volume=293|issue=21|pages=2626–33|pmid=15928284|doi=10.1001/jama.293.21.2626|display-authors=etal|doi-access=free}}</ref> and critical care during the journey.<ref name="pmid7832345">{{cite journal|vauthors=Burney RE, Hubert D, Passini L, Maio R|title=Variation in air medical outcomes by crew composition: a two-year follow-up.|journal=Ann Emerg Med|year=1995|volume=25|issue=2|pages=187–92|pmid=7832345|doi=10.1016/s0196-0644(95)70322-5|doi-access=free}}</ref> A disadvantage is that it can be dangerous and potentially not possible for them to fly at night or in bad weather.<ref>Meier, B, Saul, S. Fatal crashes provoke debate on safety of sky ambulances. New York Times, 28 February 2005.</ref><ref>Levin, A, Davis, R. Surge in crashes scars air ambulance industry. USA Today, 18 July 2005.</ref>

===Tactical (hazardous area)===
{{See also|Tactical emergency medical services}}
[[File:FDNY Haz-Tec.JPG|thumb|[[New York City Fire Department]] Haz-Tac Ambulance]]
Some EMS agencies have set up specialist teams to help those injured in a major incident or a dangerous situation.<ref name="ems1-tactical">{{cite web|url=https://www.ems1.com/ems-education/articles/1482674-Tactical-EMS-An-overview/|title=Tactical EMS: an overview|date=2013-07-31|access-date=2018-11-06|archive-date=7 August 2019|archive-url=https://web.archive.org/web/20190807135531/https://www.ems1.com/ems-education/articles/1482674-Tactical-EMS-An-overview/}}</ref> These include [[Police tactical group|tactical police operation]]s, [[active shooter]]s, [[bomb]]ings, [[Dangerous goods|hazmat]] situations, building collapses, fires and [[natural disaster]]s. In the US, these are often known as Tactical EMS teams and are often deployed alongside police [[SWAT]] teams.<ref name="ems1-tactical"/> The equivalent in UK ambulance services is a [[Hazardous Area Response Team]] (HART).

===Wilderness===
[[Image:Ambulanza (new).jpg|thumb|[[Water ambulance]] in [[Venice]], Italy]]
Wilderness EMS-like systems (WEMS) have been developed to provide medical responses in remote areas, which may have significantly different needs to an urban area. Examples include the [[National Ski Patrol]] or the regional-responding Appalachian Search and Rescue Conference (USA based). Like traditional EMS providers, all wilderness emergency medical (WEM) providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the [[Wilderness Medical Society]] and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course,<ref>{{cite journal|author=Hawkins, SC|title=Wilderness EMS Medical Director Course|journal=Wilderness Medicine|volume=29|issue=1|pages=24–25|date=21 January 2012}}</ref> which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011.<ref>{{cite web|publisher=Journal of EMS|title=Blazing a Trail|url=http://m.jems.com/article/administration-and-leadership/blazing-trail|archive-url=https://archive.today/20120718022117/http://m.jems.com/article/administration-and-leadership/blazing-trail|archive-date=18 July 2012|access-date=2012-03-30}}</ref> Skills taught in WEMT courses exceeding the EMT-Basic scope of practice include catheterization, antibiotic administration, use of intermediate [[Blind insertion airway device|Blind Insertion Airway Devices]] (i.e. [[Laryngeal tube|King Laryngeal Tube]]), [[Nasogastric Intubation]], and simple suturing;<ref>{{cite web|title=WILDERNESS EMT: TO TAKE OR NOT TO TAKE|url=https://www.remotemedical.com/wilderness-emt/|access-date=2017-10-31|date=2013-10-15}}</ref> however, the scope of practice for the WEMT still falls under BLS level care. A multitude of organizations provide WEM training, including private schools, non-profit organizations such as the [[Appalachian Center for Wilderness Medicine]]<ref>{{cite web|title=Appalachian Center for Wilderness Medicine|url=http://www.appwildmed.org/|access-date=2012-03-30|archive-date=7 August 2019|archive-url=https://web.archive.org/web/20190807192421/https://www.appwildmed.org/}}</ref> and the Wilderness EMS Institute,<ref>{{cite web|title=Wilderness EMS Institute|url=http://www.wemsi.org|url-status=usurped|archive-url=https://web.archive.org/web/20120415083720/http://www.wemsi.org/|archive-date=2012-04-15|access-date=2012-03-30}}</ref> military branches, community colleges and universities,<ref>{{cite web|title=Roane State Wilderness First Responder|url=http://www.roanestate.edu/webfolders/HAGEMANEA/healthSciences/2011TremontBrochure.pdf|access-date=2012-03-30|archive-url=https://web.archive.org/web/20121107010032/http://www.roanestate.edu/webfolders/HAGEMANEA/healthSciences/2011TremontBrochure.pdf|archive-date=7 November 2012}}</ref><ref>{{cite web|title=University of Utah Wilderness and EMS Fellowship|url=http://www.utahhealthsciences.net/pageview.aspx?id=17053|access-date=2012-03-30|archive-date=7 August 2019|archive-url=https://web.archive.org/web/20190807192408/http://www.utahhealthsciences.net/pageview.aspx?id=17053}}</ref> EMS-college-hospital collaborations,<ref>{{cite web|title=Carolina Wilderness EMS Externship|url=http://www.blueridgehealth.org/wildems|access-date=2012-03-30|archive-url=https://web.archive.org/web/20120402133115/http://www.blueridgehealth.org/wildems/|archive-date=2 April 2012}}</ref> and others.

== Occupational Health Hazards in EMS ==

=== Hazards ===
The rate of [[Occupational injury|occupational injuries]] for EMS workers is greater than the rate for the general population.<ref name=":0">{{Cite journal|last1=Reichard|first1=Audrey A.|last2=Marsh|first2=Suzanne M.|last3=Tonozzi|first3=Theresa R.|last4=Konda|first4=Srinivas|last5=Gormley|first5=Mirinda A.|date=2017|title=Occupational Injuries and Exposures among Emergency Medical Services Workers|journal=Prehospital Emergency Care|volume=21|issue=4|pages=420–431|doi=10.1080/10903127.2016.1274350|issn=1545-0066|pmid=28121261|pmc=10227644}}</ref> Occupational hazards for [[health professional]]s are well studied and generally apply to EMS. Occupational health hazards in emergency medical services include lifting injuries, violent patients, transportation incidents and harmful exposures (exposure to loud noises, chemicals and infectious diseases).<ref name=":1">{{Cite web|last=CDC|date=2024-04-23|title=About EMS Clinician Safety|url=https://www.cdc.gov/niosh/ems/about/index.html|access-date=2024-11-17|website=Emergency Medical Services|language=en-us}}</ref>

[[National Institute for Occupational Safety and Health|The National Institute of Occupational Safety and Health]] (NIOSH) established that the most common injury/illness of EMS clinicians are sprains/strains (41%) and exposures (20%).<ref name=":0" /> The occupational hazard with the greatest rate of lethality in Emergency Medical Services is ground and air ambulance crashes.<ref name=":2">{{Cite report|url=https://rosap.ntl.bts.gov/view/dot/68225|title=Analysis of Ground Ambulance Crash Data From 2012 to 2018|last1=Graham|first1=Lindsey A.|last2=Thomas|first2=Dennis|date=2023-07-01|issue=DOT HS 813 480|language=English|last3=Finstad|first3=Kraig A.|last4=Dennert|first4=Rachel|last5=Southcott|first5=Tyler}}</ref> Crashes are uncommon and Injuries from crashes make up less than 8% of injuries to EMS clinicians.<ref name=":0" />

=== Hazard Mitigation ===
In the US, [[Occupational Safety and Health Administration|OSHA]] and [[Centers for Disease Control and Prevention|CDC]] associated [[National Institute for Occupational Safety and Health|NIOSH]] have published guidelines to protect EMS workers from the occupational hazards presented by the job's requirements. These guidelines include sanitization practices, PPE requirements, and fatigue protocols.<ref name=":1" /> Fundamental facets of safety, such as providing workers with clear roles and clear communication of expectations to discourage risk-taking and encourage safe practices are essential to minimize occupational hazards.<ref>{{Cite journal |date=8 August 2023|title=Influence of communication determinants on safety commitment in a high-risk workplace: a systematic literature review of four communication dimensions|journal=  Frontiers in Public Health|pmc=10442955 |last1=Zara |first1=J. |last2=Nordin |first2=S. M. |last3=Isha |first3=A. S. |volume=11 |article-number=1225995 |doi=10.3389/fpubh.2023.1225995 |doi-access=free |pmid=37614453 |bibcode=2023FrPH...1125995Z }}</ref>

Overexertion injuries can be avoided with core training, increasing flexibility, and improving muscular endurance.<ref>{{Cite web|last=Fass|first=Bryan|date=15 November 2009|title=EMS Injury Prevention|url=https://www.hmpgloballearningnetwork.com/site/emsworld/article/10319952/ems-injury-prevention|access-date=2024-11-17|website=hmpgloballearningnetwork.com}}</ref>  Safe lifting form is encouraged.  Exposure to  chemical, biological, sensory and physical hazards can all be mitigated with an increased use of PPE.<ref>OSHA, B. N. this. (27 December 2009). Protecting EMS responders during treatment and transport of victims of hazardous substance releases. Best Practices for Protecting EMS Responders -Transport of Patients Exposed to Hazardous Materials. [https://www.osha.gov/sites/default/files/publications/OSHA3370-protecting-EMS-respondersSM.pdf https://issuu.com/safetyweb/docs/osha3370-protecting-ems-responderssm/78]</ref> Psychosocial hazards such as job stress and exposure to violence or trauma can be managed with peer support resources for emergency responders who are suffering mental health effects.<ref>{{Cite web|date=5 March 2024|title=Responder Peer Support|url=https://www.samhsa.gov/dtac/disaster-responders/peer-support|access-date=2024-11-17|website=samhsa.gov|language=en}}</ref> Most (80%) of states have established independent agency critical incident stress debriefing/management (CISD/M) programs that come into action whenever an incident is deemed particularly traumatic.<ref>{{Cite web|title=NASEMSO.org NASEMSO Releases 2020 National EMS Assessment|url=https://nasemso.org/news-events/news/news-item/nasemso-releases-2020-national-ems-assessment-2/|access-date=2024-11-17|website=nasemso.org}}</ref> Transportation related injury and fatality can be minimized with better driver training programs and protocols.<ref name=":2" />

==<span id="Org"></span>Organization in different countries==
{{colbegin|colwidth=30em}}
*[[Emergency medical services in Austria]]
*[[Emergency medical services in Australia]]
*[[Emergency medical services in Belgium]]
*[[Healthcare in Brazil#Emergency medicine|Emergency medical services in Brazil]]
*[[Emergency medical services in Canada]]
*[[Emergency medical services in Finland]]
*[[Emergency medical services in France]]
*[[Emergency medical services in Germany]]
*[[Emergency medical services in Hong Kong]]
*[[Emergency medical services in Iceland]]
*[[Emergency medical services in Iran]]
*[[HSE National Ambulance Service|Emergency medical services in Ireland]]
*[[Emergency medical services in Israel]]
*[[Emergency medical services in Italy]]
*[[Emergency medical services in the Netherlands]]
*[[Emergency medical services in New Zealand]]
*[[Emergency medical services in Norway]]
*[[Emergency medical services in Pakistan]]
*[[Emergency medical services in Poland]]
*[[Emergency medical services in Portugal]]
*[[Emergency medical services in Romania]]
*[[Emergency medical services in Russia]]
*[[Emergency medical services in Spain]]
*[[Emergency medical services in South Africa]]
*[[Emergency medical services in Sri Lanka]]
*[[Emergency medical services in Ukraine]]
*[[Emergency medical services in the United Kingdom]]
*[[Emergency medical services in the United States]]
*[[Emergency medical services in Switzerland]]
{{colend}}

==See also==
* [[Battlefield medicine]]
* [[CEN 1789]]
* [[First Aid Care Team]], a rapid-response emergency unit in Chicago disbanded in 2005.
* [[Good Samaritan law]]
* [[In case of emergency]], a programme that enables EMS workers to identify victims and contact their next of kin to obtain important medical information
* [[List of EMS provider credentials]]
* [[Mass Gathering Medicine]]
* [[Medical amnesty policy]]
* [[Public utility model]], a model for organizing Emergency Medical Services
* [[Star of Life]]
* [[Wilderness medicine]]

==References==
{{Reflist}}

==Further reading==
*''Planning Emergency Medical Communications: Volume 2, Local/Regional Level Planning Guide'', (Washington, D.C.: National Highway Traffic Safety Administration, US Department of Transportation, 1995).
*  Prener, Christopher.  ''Medicine at the Margins: EMS Workers in Urban America'' (Fordham University Press, 2022) [http://www.h-net.org/reviews/showrev.php?id=58656 online review]

==External links==
{{Commons category|Emergency medical services}}
*[http://www.euro.who.int/__data/assets/pdf_file/0016/114406/E92038.pdf "Emergency Medical Services in the European Union: report of an assessment project co-ordinated by the European Union"] {{Webarchive|url=https://web.archive.org/web/20110524094252/http://www.euro.who.int/__data/assets/pdf_file/0016/114406/E92038.pdf |date=24 May 2011 }}
*[https://web.archive.org/web/20120125234740/http://www.who.int/violence_injury_prevention/publications/services/04_07_2005/en/index.html World Health Organization: Department of Violence and Injury Prevention "Prehospital Trauma Care Systems"]
*[https://www.cdc.gov/niosh/emres/safety/index.html Safety Guidelines: Emergency Response and Recovery Workers], by the [[National Institute for Occupational Safety and Health]]

{{Emergency medical services}}
{{EMSworld}}
{{Emergency medicine}}
{{Allied health professions}}
{{Authority control}}

{{DEFAULTSORT:Emergency Medical Services}}
[[Category:Emergency medical services| ]]
[[Category:Lifesaving]]