Ambulance

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For other uses, see Ambulance (disambiguation).

An ambulance in San Jose Del Cabo, Mexico

A Helicopter used as an Ambulance. See main Air Ambulance page. This is a Eurocopter EC 135.

HMHS Britannic, a hospital ship

An ambulance is a vehicle for transporting people to or from a place of treatment for an illness or injury, or a vehicle designed to bring the medical care to the patient. An ambulance may travel from the site of an accident or injury to a hospital, from a hospital to a patient's home, or between two points of treatment (such as between a doctor's surgery and a hospital with specialist facilities).

The term ambulance comes from the Latin word ambulare, meaning to walk or move about.^[1] It is most commonly associated with the land based, motorized emergency vehicles administering emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with flashing warning lights and sirens in order to facilitate their movement through traffic. It is these emergency ambulances that are most likely to display the Star of Life^{[citation needed]}, shown on the right, which represents the six stages of prehospital medical care.

There are several other types of ambulance. Probably the most common is the patient transport ambulance. These vehicles are not usually (although there are exceptions) equipped with a high level of equipment, and are usually crewed by staff with a lower qualification than those working on emergency ambulances. Their purpose is simply to collect patients from, or drop them off at, their place of medical treatment. In most countries, these are not equipped with flashing lights or sirens.

Other vehicles used as ambulances include trucks, vans, station wagons, buses, helicopters, Fixed-wing aircraft, boats, and even hospital ships.

1 Ambulance functional types
2 Ambulance vehicle types
3 History
4 Design and construction
- 4.1 Intermediate technology ambulances
5 Appearance and markings
6 Ambulance service providers
7 Costs
- 7.1 Fake ambulance service
8 Ambulance crew
9 Military ambulances
10 Ambulances around the world
11 See also
12 References and notes
- 12.1 Additional material from

[edit] Ambulance functional types

Ambulances can be grouped into types depending on their function; that is whether or not they transport patients, and under what conditions:

Emergency Ambulance - The most recognised type of ambulance, which provide care to patients with an acute illness or injury. These can be road going Vans, helicopters, fixed-wing aircraft (known as air ambulances) or even converted vehicles such as Golf carts.
Patient Transport Ambulance - A vehicle which has the job of transporting patients to, from or between places of medical treatment, such as hospital or dialysis center, for non-urgent care. These can be vans, buses or other vehicles.
Response Unit - Also known as a fly-car, which is a vehicle which is used to reach an acutely ill patient quickly, and provide on scene care, but lacks the capacity to transport the patient from the scene. Response units may be backed up by an emergency ambulance which can transport the patient, or may deal with the problem on scene, with no requirement for a transport ambulance. These can be a wide variety of vehicles, from standard cars, to modified vans, motorcycles, pedal cycles, quad bikes or horses. In some services, these units also function as supervisors' vehicles (similar to a fire chief's vehicle, but for ambulance services).
Charity Ambulance - A special type of patient transport ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the United Kingdom's 'Jumbulance'[1] project.^[2] These are usually some form of bus.

[edit] Ambulance vehicle types

Ambulances can be based on many types of vehicle:

Van - A typical ambulance is of a van construction, based on a standard chassis, usually with a maximum road weight loaded of between 3.5 and 7.5 tonnes.
Car/SUV - Used either as a fly-car for rapid response or for patients who can sit, these are standard car models adapted to the requirements of the service using them. Some cars are capable of taking a stretcher with a recumbant patient, but this often requires the removal of the front passenger seat, or the use of a particularly long car. This was often the case with early ambulances, which were converted (or even serving) hearses, as these were some of the few vehicles able to accept a human body in a recumbent position).
Motorcycle - Used almost exclusively for rapid response in an emergency as they can travel through heavy traffic much faster than a car or van.
Bicycle - Also used for response, but usually in pedestrianised areas where road vehicles find access difficult.
Quad Bike (All Terrain Vehicle) - Used for response off road, especially at events. Some Quad bikes are modified to carry a stretcher, and are used for tasks such as mountain rescue in inaccessible areas.
Golf cart - Also used for rapid response at events. Function similar to ATVs, with less rough terrain capability, but also less noise.
Helicopter - Usually used for emergency care, either in places inaccessible by road, or in any area where speed is of the essence, as they are able to travel significantly faster than a road ambulance.
Fixed-wing aircraft - These can be used for either acute emergency care in remote areas (such as in Australia, with their 'Flying Doctors') or for patient transport over long distances (usually a re-patriation following an illness or injury in a foreign country).

Emergency and disaster conditions may lead to makeshift ambulances, in which a vehicle designed for other uses is used to provide patient transport.

[edit] History

A horse drawn ambulance from the American Civil War (1861-1865

Perhaps the first ambulances, in the sense of a vehicle built for and dedicated (at least in part) to the transport of injured or ill persons to a treatment center, were the ambulance volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte’s chief physician. These were two or four-wheeled horse drawn wagons used to transport fallen soldiers form the battlefield after they had received early treatment in the field. Half a century later, during the United States’ Civil War, military physicians Joseph Barnes and Jonathan Letterman built upon Larrey’s work and designed a prehospital care system for that included transporting wounded soldiers to treatment facilities by railroad.^[3]

Ford 1916 Model T Field Ambulance. This canvas on wood frame model was used extensively by the British & French as well as the American Expeditionary Force in World War I. Its top speed was 45mph produced by a 4 cylinder water cooled engine.

In 1867, the city of London's Metropolitan Asylums Board, in the United Kingdom, received six horse-drawn ambulances for the purpose of conveying smallpox and fever patients from their homes to a hospital. These ambulances were designed to resemble private carriages, but were equipped with rollers in their floors and large rear doors to allow for a patient, lying on a specialized bed, to be easily loaded. Space was also provided for an attendant to ride with the patient, and the entire patient compartment was designed to be easily cleaned and decontaminated. Anyone willing to pay the cost of horse hire could summon the ambulance by telegram or in person.^[4]

A 1948 Cadillac A. J. Miller ambulance. The A. J. Miller company purchased this car from Cadillac, then modified it to turn it into an ambulance. The resemblance to a hearse is obvious. (see text)

Other cities, such as Cincinnati, New York, and Paris also developed their early ambulance services due to the lessons learned from Barnes’ and Letterman’s work. In New York City, Edward Dalton, a former surgeon in the Union Army, organised ambulance services to provide faster, more comfortable transportation to the hospital. These ambulances carried medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. By the turn of the century, interns accompanied New York City ambulances, treated patients on scene, and often left them at home.^[3]

At much the same time, the automobile was being developed, and in addition to horse-drawn models, early twentieth century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. During World War One, the Red Cross provided some of the first motorised battlefield ambulances to replace horse drawn vehicles, which was such a success, the horse drawn variants were quickly phased out. In civilian emergency care, dedicated ambulance services were frequently managed or dispatched by individual hospitals, though in some areas, telegraph and telephone services enabled police departments to handle dispatch duties.^[3]

The equipment carried by the ambulance was also changing. Traction splints were introduced during World War I, 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. Shortly before World War II, then, 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 for either purpose were known as combination cars^[3]^[5]

A 1963 Cadillac Miller Meteor ambulance belonging to the Dobbs Ferry Volunteer Ambulance Corps. This ambulance resembles a hearse slightly less than the 1948 model pictured above. Volunteers continue to provide ambulance service in many areas.

Even from the early 20th century, ambulances were taking to the sky. In 1917, Lieutenant Clifford Peel, a medical student, outlined a system of fixed-wing aircraft and ground facilities designed to provide medical services to the Australian Outback. These ideas became reality under the guidance of the Very Reverend John Flynn in 1928 when the Australian Inland Mission service established the Aerial Medical Service, a one year experimental program. Physicians in this program had several responsibilities, one of which was to fly out to a patient, treat the patient, and fly the patient to a hospital if the physician could not deliver adequate care on scene. Eventually, this experiment became the Royal Flying Doctor Service of Australia.^[6]

A 1964 police cruiser, which is also fitted to transport patients. This was used before the advent of EMS services.

In much of the world, ambulance quality fell sharply during the second world war, as physicians, needed by the armed services, were pulled off of ambulances. In England, during the Battle of Britain, the need for ambulances was so great that vans were commandeered and pressed into service, often carrying several victims at once. Following the war, physicians would continue to ride ambulances in some countries, but not in others, and many other vehicles, including civilian and police cars were used to transport patients due to a lack of a dedicated resource. ^[7]^[3]

This situation persisted into the 1960s, when several events occurred that led to a redesign of the services provided by ambulance crews, and thus of the ambulance itself: CPR was developed and accepted as the standard of care for out-of-hospital cardiac arrest; defibrillation, based in part on an increased understanding of heart arrhythmias, was introduced, as were new pharmaceuticals to be used in cardiac arrest situations; in Ireland, a mobile coronary care ambulance successfully resuscitated patients using these technologies; and well-developed studies demonstrated the need for overhauling ambulance services. These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was 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), in the equipment (and thus weight) that an ambulance had to carry, and several other factors. Few, or perhaps none of the then-available ambulances could meet these standards.

Most ambulances at the time, were built on a car chassis (often based on hearses), which could not accept the weight and other demands of the new standards; van (and later, light truck) chassis would have to be used instead.^[3]^[8]

An early 1970s Cadillac Miller Meteor ambulance. By the early 1970s, the value of patient care during transport had influenced ambulance design, and in comparison to the 1963 model pictured above, this ambulance has a higher roof, and thus more room for the attendants and patient. Nevertheless, this design lacked adequate interior space to meet the ambulance standards that arose in the late 1970s. (see text)

Israeli EMS's contemporary civilian armored Mobile Intensive Care Unit. Used for response to ongoing terrorist incidents, it is based off a super-duty Ford E-450 chassis.

Ambulance design therefore underwent major changes in the 1970s. The early van-based ambulances looked very similar to their civilian counterparts, having been given some emergency vehicle equipment such as audible and visual warnings, and the internal fittings for carrying medical equipment, most notably a stretcher.

As time went on, ambulances matured in parallel to the newly developed EMS, gaining the capacity to carry additional equipment (both portable and permanently installed) as EMTs and paramedics added this equipment to their arsenal.

Modern ambulances are now often custom built (see Design and construction below), and as well as the specialist medical equipment now built in to the ambulances, industry wide improvements in vehicle design have had an impact, including improvements in audible and visual warning equipment to help protect crews in vulnerable situations (such as at a Road Traffic Collision), and general improvements such as ABS, which are particularly valuable for ambulances, due to the speeds travelled and the weight carried. There have also been improvements to help safeguard the health and welfare of ambulance crews, such as the addition of patient tail lifts, ramps and winches, to cut down on the amount of manual handling a crew must perform.

Ambulance design is still evolving, largely due to the growing skills and role of Paramedics and other ambulance crew, which require specialist equipment. Other factors driving improvement include the need to help protect ambulance crews from common accidents, such as traffic collisions and rarer, but potentially catastrophic incidents such as terrorist activities.

[edit] Design and construction

Ambulance interiors are often cramped, as seen in this Brazilian ambulance

Successful ambulance design must take in to account the local conditions and available infrastructure. Maintained roads are necessary for the familiar road going ambulances to arrive on scene and then transport the patient to a hospital, though in some areas four-wheel drive or all-terrain vehicles can make up for a paucity of good roads. Appropriate fuel must be readily available and service facilities are necessary to maintain the vehicle.

Methods of summoning (e.g. telephone) and dispatching ambulances usually rely on electronic equipment, which itself often relies on an intact power grid. Similarly, many modern ambulances are equipped with two-way radios or cellular telephones to enable them to contact hospitals, either to notify the appropriate hospital of the ambulance's pending arrival, or, in cases where physicians do not form part of the ambulance's crew, to confer with a physician for medical control.

Ambulances often have two manufacturers. The first is frequently a manufacturer of light trucks (or previously, cars) such as Mercedes-Benz or Ford. The second manufacturer purchases the vehicle (which is sometimes purchased incomplete, having no body or interior behind the driver's seat) and turns it into an ambulance by adding bodywork, emergency vehicle equipment, and interior fittings. This is done by one of two methods - either coachbuilding, where the modifications are started from scratch and built on to the vehicle, or using a modular system, where a pre-built 'box' is put on to the empty chassis of the ambulance, and then finished off.

Modern ambulances are typically powered by internal combustion engines, which can powered by any conventional fuel, including diesel, gasoline or liquefied petroleum gas,^[9]^[10] depending on the preference of the operator and the availability of different options. Colder regions often use gasoline powered engines, as diesels can be difficult to start when they are cold. Warmer regions may favour diesel engines, as they are thought to be more efficient and more durable. Some areas choose diesel power due to safety concerns, after a series of fires involving gasoline powered ambulances during the 1980s. These fires were ultimately attributed in part to gasoline's higher volatility in comparison to diesel fuel.^[11] In some cases, the type of engine may be determined by the manufacturer: Ford^[12]^[13]^[14] will only sell vehicles for ambulance conversion if they are diesel powered.

[edit] Intermediate technology ambulances

In parts of the world which lack a high level of infrastructure, ambulances are designed to meet local conditions. In some areas, ambulances are trailers, which are pulled by bicycles, motorcycles, tractors, or animals. Animal-powered ambulances can particularly useful in regions that are subject to flooding. Three-wheeled motorcycles are also used, though they are subject to some of the same limitations as more traditional over-the-road ambulances. The level of care provided by these ambulances varies between merely providing transport to a medical clinic to providing on-scene and continuing care during transport.^[15]^[16]

The design of intermediate technology ambulances must take into account not only the operation and maintenance of the ambulance, but also its construction. The robustness of the design also becomes important, as does the nature of the skills required to properly operate the vehicle. Cost-effectiveness can be a high priority.^[17]

[edit] Appearance and markings

An Italian ambulance, displaying flashing lights in the roof, above the driver's door, and in the front grille; a siren speaker on its roof; striping; the Star of Life; and the reversed ambulance sign on its hood (see text)

Emergency ambulances are highly likely to be involved in hazardous situations, including incidents such as a road traffic collision, as these emergencies create people who are likely to be in need of treatment. They are also required to gain access to patients as quickly as possible, and in many countries, are given dispensation from obeying certain traffic laws (for instance, they may be able to treat a red traffic light or stop sign as a yield ('give way') sign, or be permitted to break the speed limit.

For these reasons, emergency ambulances are often fitted with visual and/or audible warnings to alert road users.

Visual warnings on an ambulance can be of two types - either passive or active.

[edit] Passive visual warnings

The passive visual warnings are usually part of the design of the vehicle, and involve the use of high contrast patterns. Older ambulances (and those in developing countries) are more likely to have their pattern painted on, whereas modern ambulances generally carry the retro-reflective designs which reflect light from car headlights or torches (and was invented by 3M). Popular patterns include 'checker board' (alternate coloured squares, sometimes also called 'Battenburg', named after a type of cake), chevrons (arrowheads - often pointed towards the front of the vehicle if on the side, or pointing vertically upwards on the rear) or stripes (along the side - these were the first type or retro-reflective device introduced, as the original 3M reflective material only came in tape form). In some countries, in addition to retro-reflective markings, the vehicles are now painted in a bright yellow or orange colour underneath, for maximum visual impact.

Many ambulances use reflective devices to increase their visibility at night

Another passive marking form is the word ambulance spelled out in reverse on the front of the vehicle. This enables drivers of other vehicles to more easily identify an approaching ambulance in their rear view mirrors. Ambulances may also display the name of their owner or operator, and a telephone number which may be used to summon the ambulance.

Ambulances may also carry an emblem (either as part of the passive warning markings or not). Some ambulances may display a Red Cross, Red Crescent or Red Diamond (collective known as the Protective Symbols). These are symbols laid down by the Geneva Convention, and all countries signatory to it agree to restrict their use to either (1) Military Ambulances or (2) the national Red Cross or Red Crescent society. Use by any other person, organisation or agency is in breach of international law. The protective symbols are designed to indicate to all people (especially combatants in the case of war) that the vehicle is neutral and is not to be fired upon (more detail below in “military ambulances”), hence giving protection to the medics and their casualties, although this has not always been adhered to. In Israel, Magen David Adom, the Red Cross member organization use a Red Star of David, but this is not recognised beyond Israeli borders.

Many countries now use the Star of Life, shown at the top of this document, which was originally designed and governed by the U.S. National Highway Traffic Safety Administration, after legal action by the Red Cross over alleged misuse of their symbol (by using a bright orange cross, felt to be too similar to the Red Cross device). It indicates that the vehicle's operators can render their given level of care represented on the six pointed star.

[edit] Active visual warnings

The active visual warnings are usually in the form of flashing coloured lights (also known as 'beacons' or 'lightbars'). These flash in order to attract the attention of other road users as the ambulance approaches, or to provide warning to motorists approaching a stopped ambulance in a dangerous position on the road. Common colours for ambulance warning beacons are blue and red, and this varies by country (and sometimes by operator).

There are several different technologies in use to achieve the flashing effect. The original method of producing flashing was to place a spinning mirror which moves around a light bulb, called a 'rotating beacon'. More modern methods include the use of strobe lights, which are usually brighter, and can be programmed to produce specific patterns (such as a left -> right pattern when parked on the left hand side of the road, indicating to other road users that they should move out away from the vehicle). There is also the more widespread use of LED flashing lights as they are low profile and low energy. More information on Emergency vehicle equipment.

In order to maximise safety, it is best practice to have 360 degree coverage with the active warnings, improving the chance of the vehicle being seen from all sides. In some countries, such as the United States, this may be obligatory.

[edit] Audible warnings

In addition to visual warnings, many ambulances are also fitted with audible warnings, sometimes known as sirens, which can alert people and vehicles to the presence of an ambulance before they can be seen. The first audible warnings were mechanical bells, mounted to either the front or roof of the ambulance. Most modern ambulances are now fitted with electronic sirens, which can produce a range of different noises. Some ambulance services specifically train their drivers to use different siren tones in different situations. For instance, on a clear road, approaching a junction, the 'wail' setting may be used, which gives a long up and down variation, with a unbroken tone, whereas, in heavy slow traffic, a 'yelp' setting may be preferred, which is like a wail, but speeded up. The speakers for modern sirens can be integral to the lightbar, or hidden in the grill. Some ambulances may also be fitted with airhorn audible warnings.

A more recent development is the use of the RDS system of car radios, whereby the ambulance can be fitted with a short range FM transmitter, set to RDS code 31, which interrupts the radio of all cars within range, in the manner of a traffic broadcast, but in such a way that the user of the receiving radio is unable to opt out of the message (as with traffic broadcasts). This feature is built in to all RDS radios for use in national emergency broadcast systems, but short range units on emergency vehicles can prove an effective means of alerting traffic to their presence. It is, however, unlikely that this system could replace traditional audible warnings, as it is, by design, unable to alert pedestrians, or those not using a compatible radio.

[edit] Ambulance service providers

Some countries closely regulate the industry (and may require anyone working on a ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.

Government Ambulance Service - Operating separately from (although alongside) the fire and police service of the area, these ambulances are funded by local or national government. In some countries, these only tend to be found in big cities, whereas in countries such as Great Britain, almost all emergency ambulances are part of the NHS
Fire or Police Linked Service - In many countries (USA, France), many ambulances are operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance, such as Fire truck
Voluntary Ambulance Service - Some charities or non-profit companies operate ambulances, both the an emergency and patient transport function. This may be along similar lines to volunteer Fire companies and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are also charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service in many countries across the world on a volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organisations such as St John Ambulance and the Order of Malta Ambulance Corps. In some countries, these volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency.
Private Ambulance Service - Normal commercial companies with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care (i.e. non urgent), but in some places, they are also 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. In some areas, private ambulance services also respond to non-emergency home calls, such as "pick up and put back" calls, which are made when a person falls without injury, but needs help getting up. They might also provide "first aid only" services, such as providing bandages (but not a trip to the hospital emergency room) to a child who skinned his/her knees at a playground.
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 can also be found in some smaller towns and cities may also have them. 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 - Some hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependant on using the services of the providing hospital.
Charity Ambulance - This special type of ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the UK's 'Jumbulance' project [2]

[edit] Costs

In the case of a government service, it may be provided free of charge (funded through taxes), or the patient may receive a bill afterwards, to be paid by themselves or any insurance they may have. There may be a combined system where payment is from a combination of user fees for those who can afford to pay for the service, and taxpayer subsidies for those who can't In some instances, patients are not charged if they have a genuine illness or injury, but receive a bill if they make a hoax or unnecessary request for the service.

[edit] Fake ambulance service

In China, ambulance services provide business for the hospitals they serve. There have been reported cases that a hospital which was not authorized to run an ambulance service illegally did so, in an effort to increase its business.^[18]

[edit] Ambulance crew

There are several different levels of qualification that the ambulance crew may hold, from holding no formal qualification to having a fully qualified doctor on board. Most ambulance services require at least two crew members to be on every ambulance (one to drive, and one to attend the patient), although response cars may have a sole crew member, possibly backed up by another double-crewed ambulance. It may be the case that only the attendant need be qualified, and the driver might have no medical training.

Common ambulance crew qualifications are:

First Responder - A person who arrives first at the scene of an incident, and whose job is to provide early critical care such as CPR or using an AED. First responders may be dispatched by the ambulance service, may be passers-by, or may be dispatched to the scene from other agencies, such as the police or fire departments.
Ambulance Driver - Some services employ staff with no medical qualification (or just a first aid certificate) whose job is to simply drive the patients from place to place
Ambulance Care Assistant - Have varying levels of training across the world, but these staff are only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. Dependant on provider, they may be trained in first aid or extended stills such as use of an AED, oxygen therapy and other live saving or palliative skills.
Emergency medical technician - Also known as Ambulance Technician. Technicians are usually able to perform a wide range of emergency care skills, such as defibrillation, spinal care, and oxygen therapy. Some countries split this term in to several levels (such as in the US, where there is EMT-I and EMT-II). This title is not protected in all countries, such as in Great Britain, where anyone can legally call themselves an EMT, even without any training.
Paramedic - This is a high level of medical training and usually involves key skills not permissible for technicians, are cannulation (and with it the ability to use a range of drugs such as morphine), intubation and other skills such as performing a cricothyrotomy. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution.
Emergency Care Practitioner - This is a position sometimes called a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are qualified paramedics who have undergone further training, and are authorised to prescribe medicines (from a limited list) for longer term care, such as antibiotics, as well as being trained in a range of additional diagnostic techniques
Doctor - Some ambulance services - most notably air ambulances - will employ physicians to attend on the ambulances, brining a full range of additional skills such as use of prescription medicines

[edit] Military ambulances

A US M997 Ambulance emblazoned with the Red Cross

Inside of an ambulance VAB of the French Army.

Military ambulances include both ambulances based on civilian desings and armored but unarmed ambulances based upon APCs such as the FV104 Samaritan. Civilian based designs may be painted in olive, white or other colours, depending on the operational requirements — the British Royal Army Medical Corps has a fleet of white ambulances, based on production trucks. Military helicopters often function as air ambulances, since they are extremely useful for MEDEVAC.

Due to the inherently hazardous situation of a battle ground, Military ambulances are often armored, or based upon armored fighting vehicles (AFV). Since laws of war demand ambulances marked with one of the Emblems of the Red Cross not to mount any weapon, an ambulance AFV is disarmed. It is a generally accepted practice in most countries to classify the personnel attached to military vehicles marked as ambulances as non-combatants; however, this application does not always exempt medical personnel from enemy fire —deliberate or accidental. As a result, medics and other medical personnel attached to military ambulances are usually put through basic military training on the assumption that they will have to fire weaponry in a combat zone when not attending to injured personnel. The laws of war also allow non-combatant military personnel to carry individual weapons for protecting themselves and casualties, but not all militaries exercise this right.

Recently, Israel has modified some of its Merkava main battle tanks with ambulance features in order to allow rescue operations to take place under heavy fire in urban warfare. The modifications were made following a failed rescue attempt in which Palestinian gunmen killed two soldiers who aided a Palestinian woman in Rafah. Since M-113 armored personnel carriers and regular up-armored ambulances are not sufficiently protected against anti-tank weapons and improvised explosive devices, it was decided to use the heavily armored Merkava tank. Its rear door enables the evacuation of critically wounded soldiers. Israel did not remove the Merkava's weaponry, claiming that weapons were more effective protection than emblems since Palestinian militants would fire at ambulances whether emblazoned or not.