How Ambulances Work

The concept of ambulances grew out of the need to transport wounded soldiers from the battlefield, rather than leaving them behind to succumb to their injuries, die of hunger or thirst, or fall into the hands of enemies.

In the 500s C.E., the Byzantine Emperor Mauricius outfitted rescue squads of horsemen with special saddles that enabled them to carry wounded men to field hospitals. In the 11th century, crusaders came up with the innovation of wagons, staffed by nurses. By the early 1700s, European cities were using corps of volunteers to carry injured civilians on foot using stretchers. Starting in the late 1770s, volunteers switched to horse-drawn vehicles [source: Pollock].

Shortly after the American Civil War, Dr. Edward Barry Dalton, a former army surgeon appointed to head the Metropolitan Sanitary District in New York and surrounding counties, developed what probably was the first modern-style ambulance system, in order to cope with a cholera epidemic. Police and sanitation inspectors who came upon a sick person would contact a dispatcher by telegraph, who then sent a wagon staffed by a disinfection team, which then transported the patient to a hospital.

That organized approach worked so well that in 1869, New York's Bellevue Hospital started a hospital-based ambulance service [source: Pollock]. In fact these four principles (calling in, dispatch, transportation and hospital) are still the core of the modern ambulance system, even if the modes of delivery might have changed.

The development of the automobile in the late 1800s made it possible to transport patients much faster than horses could. The first motor ambulance, an electric-powered vehicle owned by a hospital in Chicago, took to the streets in 1899. In the early 20th century, the addition of pneumatic rubber tires was a life-saving innovation, because it made the ride smoother and kept patients from suffering further injuries on the way to the hospital [source: Bell].

By the 1950s, ambulances were all over the place in the U.S., but the business of picking up the sick and injured was often chaotic and haphazard. In addition to hospitals and fire departments, towing operators got into the act, as well as funeral home operators. There weren't a lot of rules or regulation until the mid-1960s, when passage of the National Highway Traffic Safety Act standardized training for emergency workers [source: West Virginia Department of Education].

In 1973, 300 EMS systems were established throughout the U.S. Over the next several decades, with the help of additional federal regulation and funding, emergency medical services began to develop into the sophisticated systems that we have today [source: West Virginia Department of Education].

At the first responder level, police officers and firefighter crews sometimes provide basic medical care. But they normally don't transport patients, explains Scott Buchle, program manager for Penn State Health Life Lion EMS in Hershey, Pennsylvania. That's the job of ambulances, which also have the ability to respond to more complicated situations.

According to Buchle, there are two basic types of ground ambulances, differentiated by the level of care they are capable of providing.

The basic life support (BLS) ambulance typically has two EMTs who can assess patients, identify their health problems and provide them with basic care, including oxygen for patients who are having difficulty breathing. BLS crews also are trained on how to extricate car crash victims from the wreckage of their vehicles. They're also equipped with automated defibrillator devices that they can use to shock the heart of a patient who goes into cardiac arrest. They also carry NARCAN, an opioid antidote that's used to treat overdoses.

The next level of service is provided by advanced life support (ALS) ambulances, which are staffed by paramedics and nurses, who have advanced training, as well as EMTs. An ALS team can respond to more complicated health situations, and is able to provide a higher level of care, such as administering medications and initiating intravenous (IV) therapy to deliver the drugs directly into a patient's veins.

In addition to full ambulances, EMS services also may use chase cars — basically, passenger vehicles that will transport an additional paramedic and his or her equipment to the scene of a medical emergency, until an ambulance can get there. At that point, the paramedic will jump on the ambulance and accompany the patient back to the hospital.

The type of vehicle sent to a call depends upon the nature of the emergency. A BLS ambulance might handle a patient with a broken leg, but if that person is in cardiac arrest, a dispatcher may send an ALS vehicle instead, according to Buchle.

Ambulances come in a variety of vehicle types and configurations, according to Dr. Ben Weston, M.D., an assistant professor of EMS medicine at Medical College of Wisconsin, who also works as a medical director for two local government EMS services. There's the familiar minivan style, but other ambulances have a pickup-truck chassis with an attached patient compartment.

Inside, ambulances carry an assortment of lifesaving equipment. BLS ambulances carry portable oxygen supplies and masks, cervical collars, slings, backboards to protect patients with spinal injuries, and kits with towels, dressings, scissors, clamps and sterile gloves to use in delivering babies. Among other equipment, they're also equipped with disinfectant, shoe covers, coveralls and other gear for controlling exposure to infections [source Facs.org].

At the ALS level, vehicles have more sophisticated devices, including intubation equipment and gear to treat patients with pneumothorax, or collapsed lung. They also often have the tools to take blood samples and perform simple lab tests, which can be transmitted directly to the hospital while in route.

One of the most important — and costly — pieces of equipment on an ALS ambulance is the heart monitor. "It's one of the essentials," Buchle says. The devices that Life Lion EMS uses are capable of doing an electrocardiogram (EKG), and also transmitting the readings via wireless modem to a doctor at the hospital while they are in route. Additionally, the device can check oxygen levels and blood pressure, and even act as a pacemaker for patients whose hearts need such assistance.

Ambulances also carry supplies of medications, with state regulations determining what they're allowed to have. ALS ambulances can carry an extensive assortment of drugs, from various cardiac medications and drugs to treat patients who've suffered allergic reactions or asthma attacks. There also are various pain medications, ranging from aspirin to fentanyl [source: Buchle].

Another useful piece of equipment on ambulances these days is a laptop computer, which crews can use to receive detailed information from the 911 dispatcher. That enables them to be better prepared when they arrive on the scene.

Ground ambulances generally are staffed by at least two EMS workers, both of whom are trained to drive the vehicle. Driving is a vital skill for ambulance crews, whose members usually take turns behind the wheel. They receive special training to enable them to get to the scene of an emergency safely, as well as quickly.

Defensive driving skills are crucial. "We have to be in the mindset that people don't necessarily see or hear us, despite the lights and the sirens," Buchle explains. "Cars are built to be insulated from road sounds, and distracted drivers are probably the worst thing we have to deal with.

So, who are the people onboard the ambulance? They are usually EMTs, but sometimes paramedics as well.

Emergency medical technicians (EMTs), spend six months in school to learn basic life support measures. Paramedics, in contrast, typically undergo two years of training, and have more advanced emergency care skills, says Buchle.

Critical care nurses are often a part of air ambulance crews. Their advanced skills can be important for keeping gravely injured trauma patients alive as they're being transported from smaller hospitals to big trauma centers for care and surgery. Some helicopter teams may include a physician as well.

When there is a medical emergency and someone calls 911 for help, they talk to a 911 dispatcher. He or she typically will ask questions from a standardized script, and type the answers into the 911 center's computer system. Sometimes, the system will automatically pick the response, though there's always a human involved in the decision as well, according to Buchle.

But who actually answers the call depends upon where the caller is. Big cities and suburban counties have their own government-run EMS systems (supported by taxpayers), while other communities may have a mix of hospital-based, private for-profit, and private non-profit ambulance companies that have contracts to handle emergency care in those places. For instance, in one city, a fire department might respond to critical cases, while a private company might handle non-life-threatening issues. In addition, many municipalities have mutual aid agreements with other nearby communities, who can send their ambulances to fill in if needed. But it's not a case of various ambulances competing for the same business. Counties contract with just one company to handle their ambulance needs or if there are more than one, each one would handle a specific need or region.

The National Association of Emergency Medical Technicians broke down the makeup of the ambulance system in the U.S. in 2017 as follows [source: Calams]:

According to a study published in 2017 in the journal JAMA Surgery, across the U.S. there's an average interval of seven minutes between a 911 call and an ambulance arriving on the scene. But that wait averages 13 minutes in rural areas, and in some isolated places, it can be up to 30 minutes before help arrives [source: American College of Emergency Physicians].

This delay has been a problem in some counties and states. For instance, in Dekalb County in Atlanta, Georgia, ambulances in 2018 had routinely exceeded the county goal of nine minutes by several minutes. This caused the county to threaten to pull the ambulance contract from the private company that had it. The service blamed the delays on long waits at hospitals for a bed to free up where the patient could be placed from the ambulance. To remedy the situation (and keep its contract), the ambulance service agreed to add more vehicles to fire stations and to have more paramedics on board [source: Berard].

Ambulances and the equipment and people who staff them don't come cheap. A typical vehicle can cost $125,000 to $150,000, and some models can be even pricier. The cardiac monitor that keeps heart patients safe on the way to the hospital typically runs another $40,000, and a device called a LUCAS compression machine, which applies better compressions to a cardiac arrest patient than a human EMT or paramedic could, runs around $15,000. Even a stretcher can cost $20,000 [source: Mendelowitz].

Those costs, coupled with the increasing tendency of municipalities to contract out their EMS services to for-profit companies, can make even short ambulance rides expensive. And health insurance companies don't always cover the costs.

NBC News reported in 2018 on the case of a teenage boy who was transported to the hospital (a ride of less than 2 miles [3.2 kilometers]) with what his doctor initially feared was a punctured lung, though it turned out to be a pulled muscle. Even so, the teen required extensive care along the way, and insurance would cover only $400. To their shock, the family received a bill for $2,400, though the ambulance service eventually agreed to reduce it to $1,600. The boy's parents didn't realize that a private ambulance service would be picking him up when they called 911 [source: Thompson].

Many patients have been shocked by the bills they receive for their ambulance trips to the ER. EMS systems counter that having all the equipment we mentioned earlier on board (even if it's not used in a particular case) is expensive. And ambulance services are generally only reimbursed for ambulance rides to a hospital, but the EMTs and other personnel are paid hourly by the service even if they don't have any calls that day, since they have to be on call with no time to spare.

Further, reimbursement rates from Medicare and Medicaid haven't changed in the last 20 years. Medicaid, in particular, pays 40 percent below what an ambulance ride costs. Insurance companies want to reimburse at Medicare/Medicaid rates and no more, leaving the patient on the hook for the difference. Ambulances also use private customers to "subsidize" the Medicaid and Medicare costs [source: Mendelowitz].

One solution would be for states to pass laws that would protect consumers from "balance billing" by out-of-network ambulance companies for balances beyond what their insurance companies cover. But a 2017 study by the Commonwealth Fund found that only six states offered such protections [source: Lucia, Hoadley, and Williams].

So how can you protect yourself from a high ambulance charge? If you're not encountering a life-threatening situation, you may wish to have a friend drive you to the hospital, or call a taxi or ride-sharing service, as opposed to calling 911. And it wouldn't hurt to look at your insurance policy ahead of time to know how much you're covered in case you ever need to call on the expertise of ambulance services.