What Is an Ambulance?

As the foundation of a workable national structure that will meet emergency-response requirements, the Department of Homeland Security (DHS) created and is relying on two major documents – one describing the National Incident Management System (NIMS), the other establishing a National Response Plan (NRP). Within the latter, EMS (emergency medical services) falls firmly under ESF-8 – Emergency Support Function (Health and Medical Services) – and plays a vital role in the nation’s medical system.

Nationally, EMS is now provided by an amalgam of government agencies, volunteer organizations, hospitals, and private companies. This patchwork semi-organization is a residue of decades of non-inclusion of EMS units in disaster-preparedness plans and the decades-long reliance, by many cities and states, on private resources to provide emergency medical services.

Modern EMS can trace its roots back to concepts developed for the civilian community in the 1950s that were based on the lessons learned in combat during World War II and later upgraded and refined in the Korean War. The doctrinal genesis of modern EMS, however, lies in the 1966 publication by the National Highway Transportation Safety Administration (NHTSA) of a White Paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society.”

Two Strong Men and a Station Wagon

The NHTSA document precipitated the transformation of ambulance services from little more than two strong men in a station wagon to the modern model in which effective medical care is provided both at the scene of a life-threatening accident or disaster and en route to the hospital. Prior to this change, about half of all ambulances in the United States were run by mortuaries (primarily because their vehicles were big enough to carry at least one stretcher patient).

Accompanying the shift to a more professional, medically grounded EMS was the growth of ambulance transportation as a business. After ambulance companies were able to bill Medicare/Medicaid and/or medical-insurance companies for their services there was a virtual explosion in the number of ambulance businesses and operators available. That unprecedented and somewhat unregulated growth eventually was brought under control in many states by a certificate-of-need process that requires the demonstration of a need prior to the authorization of any individual or business to operate an ambulance service.

About 125 of the nation’s 200 largest cities now rely on the private sector to provide at least some if not all of the critical emergency services needed in those cities.

In recent years, many communities have been either consolidating their EMS services into their police or fire departments, or privatizing their EMS systems. One unfortunate result, though, has been a lack of consistency in regard to the type and structure of EMS resources and capabilities available nationally. Although fiscal realities may have forced these changes, the bottom line, according to a 2004 survey by the Journal of Emergency Medical Services, is that about 125 of the nation’s 200 largest cities now rely on the private sector to provide at least some if not all of the critical emergency services needed in those cities.

A Partial Solution Under NIMS

One of the more important questions facing local and state officials is how to ensure that private-sector ambulances are fitted with the same types and quantities of equipment available to those of their municipal counterparts, and that private-sector EMS personnel possess a level of training equivalent to that required for city, state, and federal EMS employees. Experience has shown that the vast majority of EMS personnel working in for-profit ambulance companies are, in fact, highly trained and dedicated professionals. However, as private businesses, the companies that employ these skilled workers often are not eligible for the same grants and other publicly funded programs available to the EMS professionals themselves.

Similarly, agencies that rely on volunteers for staffing often have trouble motivating them to take any but the absolute minimum training – primarily, it seems, because most if not quite all volunteers not only are donating their time but also are putting in a full day’s work in their other jobs. The NIMS plan provides at least a partial solution to this problem.

Although no incident-management system will correct the economic and historical disparities that have led the nation’s EMS resources to the current state of semi-confusion, NIMS can and does help level the playing field on the day an actual incident occurs. One of the more important issues addressed by the NIMS guidelines is resource management. As already has been demonstrated in certain incidents that reached the level of “national significance,” the control of resources is the key to success in responding to almost any emergency.

A principal focus of resource management under NIMS is resource typing – or, more simply put, the categorizing of similar resources by capability. The first step to understanding resource typing in EMS is to recognize that, although there are a number of state-to-state variations in other particulars, most ambulances can be categorized as either BLS (basic life support) or ALS (advanced life support) vehicles. The equipment and (to a somewhat lesser extent) personnel specifications for each category of vehicle can easily be spelled out, thus eliminating at least some previous uncertainties.

Consistency Requirements and the EMAC Solution

When resources are needed during an incident they usually are drawn, initially, from the community where the emergency occurs. This means that there is not only a consistency of resources but also that those requesting and those providing the resources both understand and expect the same consistency. Resource typing is intended to ensure that the consistency continues if and when the need to respond to a major incident requires using other resources drawn from other, usually more distant, jurisdictions.

Resource typing allows incident commanders not only to request what they need but also to expect a minimum level of consistency regardless of the source. A simple example would be an incident commander requesting an ALS unit. If resource typing was in place beforehand the request might be for a type-I ALS ambulance. Because the providing agency had previously agreed on what a type-I ALS unit is, the result will or should be a consistent resource. (In the case postulated, that resource would be a paramedic unit that can transport two patients and that possesses a specific set of equipment, as well as EMS personnel with the training specified.)

Resource typing allows incident commanders not only to request what they need but also to expect a minimum level of consistency regardless of the source.

This consistency requirement carries through the other types of EMS units. The collective state/local/federal EMS goal is to develop and use a common vocabulary so that both the requesting agency and the providing agency know and agree, in specific detail, what is being requested and what is being provided. Nonetheless, it still happens that, when one town is requesting a resource from a neighboring town in the same geographic community, the definition of the resource is often understood – unless there has previous discussion between the two towns. When the towns are adjacent to one another this usually is not a problem, because the same rules almost always apply to both towns. However, this expectation becomes less and less certain as the distance between the requester and the provider grows.

Emergency Management Assistance Compacts (EMACs) – i.e., state-to-state mutual-aid agreements – allow states to request assistance from and/or lend assistance to other states in the same area of the country. Having a common language to describe the resources requested will allow the fulfillment of EMAC requests not only to be more meaningful – and, therefore, both more productive and more effective – but also to the saving of additional lives.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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