security and emergency preparedness, separate from the new orleans fire department. charity/not-for-profit ambulance service a volunteer ambulance crew in modena, italy charities or non-profit companies operate some emergency medical services. they are primarily staffed by 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. (in some countries, it operates as a private ambulance service). other organisations include st john ambulance, the order of malta ambulance corps and hatzalah, 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. private/corporate ambulance service 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. in latin america, private ambulance companies are often the only readily-available ems service 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 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 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 plants, 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. purpose 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: early detection – members of the public, or another agency, find the incident and understand the problem early reporting – 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 – the first professional (ems) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin good on-scene/field care – 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 -– 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 – the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians strategies for delivering care training for ems in estonia. although a variety of differing 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 technicians or paramedics. these models are commonly referred to as the franco-german model and anglo-american model. studies have been inconclusive as to whether one model delivers better results than the other. 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. levels of care 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 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. 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 technicians or emergency care assistants. 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, but where it is present it usually replaces bls. advanced life support (als) has a considerably expanded range of skills such as intravenous therapy, cricothyrotomy and interpreting an electrocardiogram. the scope of this higher tier response varies considerably by country. paramedics commonly provide als, but some countries require it to be a higher level of care and instead employ physicians 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), 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 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 and undertakers may transport people to hospital. transport-centered ems 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". in this model, ambulances are staffed by paramedics and/or emergency medical technicians. 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 oversight for the work of the ambulance crews. this may include off-line medical control, where they devise 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. 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. 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. while most insurance companies only reimburse ems providers for transporting patients to 911 receiving facilities (e.g. emergency departments),the 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. 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 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 airway, breathing and