How many ambulance companies in America

Ambulance Service in the United States - Emergency medical services in the United States

Overview of Ambulance Services in the United States
This Darien, Connecticut medical services center has an outdoor emergency vehicle that can respond immediately if necessary.

In the United States , Ambulance service (EMS) provides out-of-hospital acute medical care and / or transportation to definitive care for those in need. They are regulated at the lowest level by the National Highway Traffic Safety Administration, which sets the minimum standards that states must meet for all EMS providers, and strictly regulated by individual state governments, which often require higher standards from the services they oversee .

Large differences in population density, topography, and other conditions can require different types of EMS systems. As a result, there are often significant differences between the emergency services provided in one state and those provided in another.

Organization and funding

Rural ambulance

EMS delivery in the US can be based on different models. While most services are publicly funded to some extent, the factor that often sets services apart is the way in which they are operated. EMS systems can be operated directly by the community or from a third party such as a private company. The most common operating models in the U.S. are:

Publicly operated EMS

In one of the most common publicly operated models, an EMS system is operated directly by the community it oversees. The services themselves can be provided by a local government or be the responsibility of the regional (or state) government. Services operated by the community can be financed by service fees and supplemented by property taxes. In many cases, the EMS system is viewed as too small to work independently and is organized as a branch of another community department such as the Public Health Department. In small communities with no large population or tax base, such a service may only be able to operate if it is manned by community volunteers. In these cases, the volunteer group may receive some funding from local taxes, but is generally heavily reliant on voluntary donations to cover operating costs. This presents a significant challenge for volunteer groups as it requires staff training standards and vehicle and equipment standards to be followed while the group conducts all or most of its own fundraising drives. However, without the presence of dedicated volunteers, many small communities in America could do without local EMS systems and either have no service at all or be forced to rely on services from more distant communities.

Another operating model for publicly operated EMS is what is commonly referred to in the industry as an option for the third service. With this option, the service is not an integral part (or in some cases as an “addition” to) one of the traditional “emergency services” (fire brigade and police) but is organized as a separate, free-standing service, communal department, with an organization called the fire brigade or may be similar to the police, but operated independently. In a variant of this model, the EMS system can be recognized as a legitimate third party emergency service, but is provided under a contractual arrangement with another organization such as a private company or a hospital instead of a direct operation. This model is sometimes referred to as the "public utility model". This can be a cost-saving measure or the community may feel they lack the residents' expertise to address medical oversight and control issues and the legal requirements normally placed on an ambulance service.

In another model for publicly operated rescue services, the system can be integrated into the operation of another municipal rescue service such as the local fire brigade or the police. This integration can be partial or complete. In the case of partial integration, EMS employees can share quarters, administrative services and even commands and controls with the other service. In the case of full integration, EMS personnel can be fully trained to perform the entry-level function of the other emergency services, regardless of whether it is fire fighting or police work. Many municipalities see this as "added value" for the municipality, as municipal workers perform more than one role and are less likely to be idle.

Private / for-profit EMS

Private / for-profit ambulances have a long history in the United States. In smaller communities in particular, ambulances were often viewed by the community as less important than police or fire departments, and certainly not something that should require public funding. Until the professionalization of emergency medical services in the early 1970s, one of the most common emergency service providers in the United States was a community's local funeral home. This was essentially done by default, as hearses were the only vehicles at the time that could transport a person lying down. The funeral home outpatient operations were sometimes supplemented by “mom and pop operations” that were not associated with funeral home but rather operated on the same basis as a taxi service. There were no national standards for emergency services and staff generally had little or no medical training or equipment, resulting in high pre-hospital mortality rates. Such companies continue to operate this way in some locations, providing municipalities with non-emergency transport services, chargeable emergency services, or contracted emergency services, as in the public utility model. In the late 1970s and early 1980s, more than 200 private ambulance companies in the United States gradually merged into large regional companies, some of which still exist today. As this trend continued, it resulted in some remaining private companies, a handful of regional companies, and two very large multinational companies that currently dominate the entire industry. These services continue to be offered in some parts of the United States, either for a fee to the patient or under contract with local communities. Such contracts typically result in a service fee that is additionally funded by the community in return for formal guarantees of adequate performance on issues such as personnel, skills, available resources and response times.

Model of care

The Emergency Medical Service System in the USA usually follows the Anglo-American model of service provision (bringing the patient to the hospital) in contrast to the Franco-German model (bringing the hospital to the patient). Aside from a handful of doctors working on Medevac aircraft or doing training or medical quality assurance, it is extremely uncommon for a doctor to deliberately respond to the location of an emergency.

Ambulance aircraft

Air ambulance services in the United States can be operated from a variety of sources. Some services are operated in the hospital while others may be operated by federal, state, or local governments. or through a variety of departments including local or state law enforcement, the United States National Park Service, or the fire department. Such services can be operated directly by one of these EMS systems or they can be outsourced to a third party such as an aircraft charter company. In addition, it is not uncommon for US military helicopters to be put into service in support of ambulances. While helicopters are the preferred form of emergency service delivery for on-the-spot emergencies because of the long distances traveled by the United States, fixed-wing aircraft, including small jets, are widely used for transfers from rural hospitals to tertiary care facilities. These aircraft are usually manned by a mix of staff, including doctors, nurses, and paramedics, and in some cases all three. Publicly operated air rescue services are supplemented by emergency and non-emergency air traffic services, which are provided by committed air rescue companies or by aircraft charter companies as ancillary business. 3

  • Air ambulance in the United States


Grady Ambulance Service in the United States began in Atlanta, Georgia in 1869. Grady Memorial Hospital staff rode in horse-drawn carriages designed specifically for the transportation of the sick and injured.

The first volunteer rescue workers were organized around 1920 in Roanoke, Virginia, Palmyra, New Jersey, and along the New Jersey coastline. Gradually, especially during and after World War II, hospitals and doctors disappeared from preclinical practice and gave in to centrally coordinated programs in urban areas. These were often checked by the city hospital or the fire department. Sporadically, hearses for undertakers, which had been the usual mode of transport, were replaced by fire brigades, rescue workers and private ambulances.

Before the 1970s, the ambulance service was largely unregulated. While some areas had ambulances manned by advanced first aid workers, in other areas it was common for the local undertaker, who had the only vehicles in town for a person to lie down, to have both the local furniture store (where ) he ran coffins as a sideline) and the local rescue service. However, following the publication of the National Highway Traffic Safety Administration's study, "Accidental Death and Disability: The Neglected Disease of Modern Society" (known in the EMS trade as the White Paper), a concerted effort has been made to improve emergency medical care in the preclinical setting.

In the late 1960s, Dr. R. Adams Cowley was instrumental in developing the country's first statewide EMS program in Maryland. The system was developed as a department for emergency services (today as Maryland Institute for Emergency Medical Services and Systems ) designated. Also in 1969, Cowley was given a military helicopter to quickly transport patients to the Center for Trauma Studies (now known as the R Adams Cowley Shock Trauma Center), a specialized hospital he had set up to treat shock. This service was not only the first nationwide EMS program, but also the beginning of modern rescue helicopter transportation in the United States.

The first US hospital civil medical helicopter program, Flight For Life Colorado, began in 1972 with a single Alouette III helicopter stationed at St. Anthony Central Hospital in Denver, Colorado.

The US national EMS standards are set by the US Department of Transportation and amended by the EMS department of each state (usually under the Department of Health) and further modified by regional medical advisory committees (usually in rural areas) or other committees. or even individual EMS providers. In addition, on the recommendation of President Lyndon B. Johnson, the National Register of Paramedics, an independent body, was established in 1970 to provide nationally recognized certification for providers and a nationwide consensus on protocols. Currently, some parts of the United States accept certification as a national registry, while others still have their own separate protocols and training curricula.

A major event in the development of modern standards of care in the United States was a 1966 report, commonly referred to as the "White Paper," entitled "Accidental Death and Disability: The Neglected Disease of Modern Society" by the National Academy of Sciences. "" This study revealed that many of the daily deaths were unnecessary and could be prevented through a combination of community education, stricter safety standards and better pre-hospital treatment.

In particular, in California, Seattle, Washington state (Medic One), and Miami, projects include paramedics in EMS responses in the early 1970s. Groups in Pittsburgh, Pennsylvania, Charlottesville, Virginia, and Portland, Oregon were also early pioneers in pre-hospital emergency medical training. Despite opposition from firefighters and doctors, the program eventually gained acceptance when its effectiveness became apparent.

In addition, such programs were introduced in North America in the 1970s with the NBC television series Emergency! This followed, in part, the adventures of two Los Angeles County Fire Department paramedics responding to various types of medical emergencies. James O. Page served as the series' technical advisor and became an integral part of EMS development in the United States. The popularity of this series encouraged other churches to establish their own equivalent ministries.



Ambulances in the United States must have a minimum of 2 staff members. The level of crew certification depends on the jurisdiction in which the ambulance operates. In most areas, the minimum is one EMT for patient care and one EMR for assisting and driving the device. This facility would be classified as a Basic Life Support Unit (BLS) because the highest ranked provider cannot conduct Advanced Life Support (ALS) interventions. If the patient's condition warrants, an ALS provider can be called in to assist and meet the ambulance on the way to the hospital. Other personnel combinations include a paramedic and a paramedic (the most common arrangement) or two paramedics who are classified as an Advanced Life Support Unit (ALS) in most areas. Unlike in Europe, emergency doctors do not regularly practice on site and only practice ambulances for special situations such as extremely light infant transports, ECMO or cardiac bypass transports or unusual situations such as crush injuries that require a field amputation or mass accident / disaster situations.

Financing and personnel models

EMS is sometimes provided by volunteers. Agencies that were previously only voluntary have begun to add compensated members to their ranks to keep up with the booming call volume. As of 2004, American Medical Response, based in Greenwood Village, Colorado, was the largest private enterprise provider of contract EMS services in North America. The second largest US EMS provider is the Rural / Metro Corporation, based in Scottsdale, Arizona. The Rural / Metro Corporation also provides EMS services for parts of Latin America. Like AMR, Rural / Metro also provided other transportation services, such as B. non-emergency transports and "bus" or wheelchair transports. On October 28, 2015, AMR announced that the acquisition of Rural / Metro has been completed. This makes AMR the largest EMS organization in the USA and employs almost 25,000 people.

Many colleges and universities now also have their own EMS agencies. Collegiate EMS programs vary somewhat from university to university; Most agencies, however, are fully staffed with student volunteers. The agencies may operate a so-called rapid response service (which does not transport patients, but acts as first aiders for scenes), which enables an initial assessment and care of the patients, or they operate certified emergency services, which are manned by rescue workers or paramedics. Some groups limit services to their campus while others expand services to the surrounding community. Services provided by college and university agencies may include emergency medical services, mass accident response, aero-medical services, and search and rescue teams.

While the fire service in the USA is rated using ISO classes and fire insurance rates (accident insurance) are based on these classes, EMS does not receive ratings or corresponding financial savings on health or life insurance policies. In contrast to fire and police protection, which the federal government recognizes as essential services, it has been left to local governments to determine whether emergency services are required for their communities. This lack of federal recognition as an essential service has left emergency services in the United States severely underfunded, leading to service closures and gaps in coverage for citizens across the country.

Training and certification

For a country-specific list of skill levels, see Rescue Worker Levels by US State

The original lines that demarcated an EMT from a medic and a medic from a doctor are becoming increasingly blurred. Skills that were once reserved for doctors are now routinely performed by paramedics, and skills that were once reserved for paramedics, such as B. Defibrillation, are now routinely performed by Basic Emergency Medical Technicians (EMTs). However, there are big differences between states and even between counties within the states as to what types of care providers are allowed to provide services at different levels. In addition to these variations, some states and counties allow Add-ons such as defibrillation or IV therapy, which allow lower-level workers to learn and use additional skills that would normally not be within the practice of their skill level (for example, an EMT is generally not allowed to start an IV. However, he may do so after successfully completing an IV add-on course.) Add-on skills are generally more common in rural areas The ultimate care is geographically further away and immediate emergency response is beneficial for patient care.

A basic listing of qualification levels:

  • Emergency Medical Responders (EMR): EMRs, many of which are volunteers, provide immediate primary care, including bleeding control, CPR, AED, and emergency delivery. Using an EMT, an EMR can take care of a patient while that patient is being transported.
  • Emergency Medical Technician (EMT): The EMT includes all EMR skills, advanced oxygen and ventilation skills, pulse oximetry, non-invasive blood pressure monitoring, and the administration of certain medications.
  • Advanced Emergency Medical Technician (AEMT): AEMT includes all EMT skills, advanced airway equipment, intravenous and intraosseous access, blood glucose testing, and the administration of additional medications.
  • Registered Nurse: In some countries specially trained nurses are used for pre-clinical services. These are mainly air medical personnel or providers of intensive care transports with specialized training and experience in pre-clinical care. Such nurses must apply for additional certifications from their employers beyond the basic nurse license, and often must have at least three years of full-time experience in emergency and / or critical care. Certification requirements vary but often include Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), Core Trauma Nursing Course (TNCC), and Advanced Trauma Life Support (ATLS) , in addition to Pre-Clinical Trauma Life Support (PHTLS). Standards are also certified in Onboard Emergency Nursing (CEN), Critical Care Nursing (CCRN), and Land Transport (CTRN) or Flight Nursing (CFRN) respectively. These nurses are trained and able to work at the paramedic level. In some regions, they are authorized to operate base station phones for medical commands. Some states allow them to work fully under standing order while in a ground ambulance or air medical unit (i.e., offline medically checked). The training also includes specific training relevant to the state and its protocols, and often requires the nurse to train with paramedics for a period of time and take an additional exam, which will be carried out by her medical director, before going with one Ground ambulance or an air force medical unit is allowed to operate. Many of these nurses have paramedic or paramedic certifications and are required to do so in some states, but this is not the standard of practice.
  • Paramedic ( see paramedics in the USA ): The Paramedic is a specialized healthcare provider, an autonomous physician who offers advanced assessment and management skills, various invasive skills, and extensive pharmacological interventions.

Reciprocity - that is, the recognition of EMT certification from one state in another - between states is somewhat limited, and after 30 years of operation by the national paramedic register, only about 40 states offer full recognition of NREMT certifications . In reality, there are at least 40 types of EMS employee certification in the United States, many of which are only recognized by a single state. This poses significant job mobility challenges for many EMS providers, as they often have to repeat the certification exams every time they move from one state to another.

  • Medical professionals in the United States

Medical control

EMS providers operate under the authority and indirect supervision of a medical director or board certified physician who oversees the policies and protocols of a particular EMS system or organization. Both the medical director and the actions he or she takes are often referred to as "medical control".

Equipment and procedures are necessarily limited in the pre-clinical setting, and EMS professionals are trained to follow a formal and carefully crafted decision tree (commonly referred to as a "protocol") approved by Medical Control. This protocol helps ensure a consistent approach to the most common types of emergencies that the emergency medical professional may encounter. Medical monitoring can be done online, with EMS staff contacting the doctor for a delegation of instructions for all Advanced Life Support (ALS) procedures, or offline, with EMS staff taking some or all of their ALS procedures on this basis carries out protocols or "standing orders". The NHTSA curriculum remains the standard of care for EMS organizations in the United States.



Ambulances in the United States are defined by the requirements of federal standards KKK-1822, which define several categories of ambulance. In addition, most states have additional requirements that suit their individual needs.

  • Type I ambulances are based on the chassis cabs of light pick-ups.
  • Type II ambulances are based on modern passenger / freight cars that are known in the industry as Vanbulances are called .
  • Type III ambulances are based on the chassis cabs of light delivery vans.

AD- Versions (Additional Duty) for both Type I and Type III designs are also defined. This includes increased GVWR, storage and payload capacity.

Large American cities like New York and Los Angeles usually have many different ambulance services, each with their own color scheme and using all of the above types of ambulances. Pedestrians and drivers in such cities must watch out for ambulances of many shapes, sizes, and colors. Most ambulances certified for emergency response in the United States are marked with the Star of Life so that they can be easily identified by the public.

  • EMS in the United States
  • A typical one Type I ambulance

  • A typical one Type II ambulance

  • A typical one Type III ambulance

  • A typical one medium-weight ambulance with a commercial vehicle chassis

  • A typical one Military Ambulance (US) based on an HMMWV chassis

  • Moderate combination of rescue and ambulance

Ambulances can be supplemented or supported by vehicles that are unable to transport a patient. The most common of these vehicles is known by several names, including "Response Car". Response cars are often equipped with the same equipment that is carried by an ambulance. However, since they are SUVs or large cars, they are often faster and more nimble. Emergency vehicles are manned by one or more medical providers and are used in a variety of ways as a source of additional (or more skilled) labor, as a supervisor's vehicle, or as a first vehicle to allow medical treatment to begin before the ambulance arrives.

  • Support vehicles in the United States
  • Typical heavy rescue unit

  • A typical one SUV-based paramedic known as First Responder Unit, Chase Car, or Fly-Car


There are as many methods of shipping EMS resources in the United States as there are approaches to providing EMS services. EMS may be self-dispatching in some larger communities. If EMS is operated as a department of the police or fire department, it is usually dispatched by these organizations. Shipments can be made through state-licensed EMS shipping centers that are operated by one service but allow shipping to multiple counties. In large centers like New York City, the statutory EMS provider (in the case of NYC, the FDNY) will ship not only its own vehicles but also EMS resources from hospitals, private companies, and even volunteers within its own community. The national emergency number in the United States is 9-1-1. The number works for all three emergency services. In most cases, a 9-1-1 call will be answered at a central facility, usually referred to as a public safety answer point, and in most cases operated by the police. The needs of the caller are identified and the call is forwarded to the dispatcher for the necessary emergency services.

While some small communities continue to use low-tech approaches to shipping, the technology is well advanced in many places in the United States. The advanced technologies used may include electronic mapping, the Global Positioning System (GPS), or the first cousin Automatic Vehicle Location (AVL). The use of decision support software like AMPDS is as common as monitoring add-ons. As a result, many dispatchers themselves are trained to a high level by screening incoming calls for severity and giving advice or medical instructions over the phone before the ambulance or rescue team arrives on site. Some are certified as paramedics or paramedics in their own states and are increasingly being certified as paramedics.

reaction time

The United States does not have an official federal or state standard for response times. However, response time standards often exist in the form of contractual obligations between communities and EMS provider organizations. As a result, there are usually significant differences between standards in one community and in another. For example, New York City has a 10-minute response time for emergency calls, while some California communities have moved the response time to 12-15 minutes. It is generally accepted in this area that an "ideal" response time to emergency calls would be eight minutes, ninety percent of the time, but this goal is seldom achieved and recent research has challenged the validity of this standard. As call volume increases and resources and funds do not keep pace, even large EMS systems like Pittsburgh, Pennsylvania struggle to meet these standards. People who live far away from emergency services in rural areas can expect a longer waiting time due to the distance. Different methods of measuring performance make this problem even more complex. Some services count the response time from the moment the phone call is answered and executed until an ambulance or an answering resource arrives at the scene, while others only measure the time from notifying EMS staff of the call, which is significantly shorter . Another problem that occurs in urban areas is that the "clock" response time stops almost everywhere if the device arrives before the address. In large office or residential buildings, actual patient access may take a few minutes longer, but this is not taken into account when calculating response time or reporting.

See also


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