emergency medical services emergency medical services emergency medical services (ems), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. they may also be known as a first aid squad, fast squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as emas or emars. chicago fire department paramedics transporting a patient on a stretcher an new south wales ambulance emergency medical services unit responding to a call for service 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 (such as 911 in the united states) which puts them in contact with a dispatching centre, which will then dispatch suitable resources for the call. ambulances are the primary vehicles for delivering ems, though squad cars, motorcycles, aircraft, boats, fire apparatus, and others may be used. ems agencies may also operate a non-emergency patient transport service, and some have rescue squads to provide technical rescue or search and rescue services. 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. 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. training and 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. 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 technicians (emts) and paramedics, with the latter having additional training such as advanced life support (als) skills. physicians and nurses 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. 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. larrey was present at the battle of spires, between the french and prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. having decided against using the norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. 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. 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. 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". this tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning. a horse-drawn bellevue hospital ambulance in new york city, 1895 the first known hospital-based ambulance service operated out of commercial hospital, cincinnati, ohio (now the cincinnati general) by 1865. this was soon followed by other services, notably the new york service provided out of bellevue hospital which started in 1869 with ambulances carrying medical equipment, such as splints, 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 vienna ringtheater in 1881. named the "vienna voluntary rescue society," it served as a model for similar societies worldwide. in june 1887 the st john ambulance brigade was established to provide first aid and ambulance services at public events in london. it was modelled on a military-style command and discipline structure. motorization 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. 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 hp motors on the rear axle. during world war i, further advances were made in providing care before and during transport; traction splints were introduced during the war and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. two-way radios became available shortly after world war i, enabling for more efficient radio dispatch of ambulances 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 hearses, the only available vehicle that could carry a recumbent patient, and were thus frequently run by funeral homes. these vehicles, which could serve either purpose, were known as combination cars. 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. rise of modern ems a 1973 cadillac miller-meteor ambulance. note the raised roof, with more room for the attendants and patients. advances in the 1960s, especially the development of cpr and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. 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. 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 standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), 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. such advancements included dr. r adams cowley creating the country's first statewide ems program, in maryland. 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. in france, the first official samu agencies were founded in the 1970s. 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. government ambulance service 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. 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 employees 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 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 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 and a majority of emergency transport ambulance services in large cities are part of fire departments. 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 nolaxone use or 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