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Ambulance
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An ambulance is a vehicle for transporting sick or injured people, to, from or between places of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to bring medical care to patients outside of the hospital or to transport the patient to hospital for follow-up care and further testing. The word is most commonly associated with the land-based, emergency motor vehicles that administer emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances.
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Encyclopedia
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in Austria]]
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An ambulance is a vehicle for transporting sick or injured people, to, from or between places of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to bring medical care to patients outside of the hospital or to transport the patient to hospital for follow-up care and further testing. The word is most commonly associated with the land-based, emergency motor vehicles that administer emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with flashing warning lights and sirens to facilitate their movement through traffic. It is these emergency ambulances that are most likely to display the Star of Life, which represents the six stages of prehospital medical care. Other vehicles used as ambulances include trucks, vans, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships.
The term ambulance comes from the Latin word ambulare, meaning to walk or move about which is a reference to early medical care where patients were moved by lifting or wheeling. The word originally meant a moving hospital which follows an army in its movements. During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons. Field hospitals were still called ambulances during the Franco-Prussian War of 1870 and in the Serbo-Turkish war of 1876 even though the wagons were first referred to as ambulances about 1854 during the Crimean War.
There are other types of ambulance, with the most common being the patient transport ambulance. These vehicles are not usually (although there are exceptions) equipped with life-support equipment, and are usually crewed by staff with fewer qualifications than the crew of emergency ambulances. Their purpose is simply to transport patients to, from or between places of treatment. In most countries, these are not equipped with flashing lights or sirens. In some jurisdictions there is a modified form of the ambulance used, that only carries one member of ambulance crew to the scene to provide care, but is not used to transport the patient. In these cases a patient who requires transportation to hospital will require a patient-carrying ambulance to attend in addition to the fast responder.
History
The history of the ambulance begins in ancient times, with the use of carts to transport incurable patients by force. Ambulances were first used for emergency transport in 1487 by the Spanish, and civilian variants were put into operation in 1887. Advances in technology throughout the 19th and 20th centuries led to the modern self-powered ambulances.
Functional types
Ambulances can be grouped into types depending on whether or not they transport patients, and under what conditions. In some cases, ambulances may fulfil more than one function (such as combining emergency ambulance care with patient transport).
- Emergency ambulance – The most common type of ambulance, which provide care to patients with an acute illness or injury. These can be road-going vans, boats, 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. These units can function as a vehicle for officers or supervisors (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' project. These are usually based on a bus.
Vehicle types
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Ambulances can be based on many types of vehicle, although emergency and disaster conditions may lead to other vehicles serving as makeshift ambulances:
- 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. In North America, the large box type vehicles are referred to as "mods" (modular) and the smaller van type vehicle is often called a "high-top".
- 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 recumbent 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 supine position).
- Motorcycle – In developed areas, these are used for rapid response in an emergency as they can travel through heavy traffic much faster than a car or van, although in the developing world, trailer or sidecar adaptations make these patient transporting units.
- Bicycle – Used for response, but usually in pedestrian only areas where large vehicles find access difficult. Like the motorcycle, a bicycle may be connected to a trailer for patient transport, most often in the developing world.
- All Terrain Vehicle – for example quad bikes; these are used for response off road, especially at events. ATVs can be modified to carry a stretcher, and are used for tasks such as mountain rescue in inaccessible areas.
- Golf cart – Used for rapid response at events. These function similarly to ATVs, with less rough terrain capability, but with less noise.
- Helicopter – Usually used for emergency care, either in places inaccessible by road, or in areas 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 the 'Flying Doctors') or for patient transport over long distances (usually a re-patriation following an illness or injury in a foreign country).
- Boat – Boats can be used to serve as ambulances, especially in island areas or in areas with a large number of canals, such as the Venetian boat ambulances. Some lifeboats or lifeguard vessels may fit the description of an ambulance as they are used to transport a casualty.
- Ship – Ships can be used as hospital ships, mostly operated by national military services, although some ships are operated by charities. They can meet the definition of ambulances as they provide transport to the sick and wounded (along with treatment). They are often sent to disaster or war zones to provide care for the casualties of these events.
- Horse and Cart - Especially in developing world areas, more traditional methods of transport include transport such as horse and cart, used in much the same way as motorcycle or bicycle stretcher units to transport to a local clinic.
Design and construction
Australia]]
Ambulance design must take into account local conditions and infrastructure. Maintained roads are necessary for road going ambulances to arrive on scene and then transport the patient to a hospital, though in rugged areas four-wheel drive or all-terrain vehicles can be used. Fuel must be 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, 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 oversight.
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 be powered by any conventional fuel, including diesel, gasoline or liquefied petroleum gas, 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 favor diesel engines, as they are thought to be more efficient and more durable. Diesel power is sometimes chosen 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. The type of engine may be determined by the manufacturer: Ford will only sell vehicles for ambulance conversion if they are diesel powered.
Safety
Like all vehicles, ambulances may be involved in collisions. Ambulances, like other emergency vehicles, are required to operate in all weather conditions, including those during which civilian drivers often elect to stay off of the road. Also, the ambulance crew's responsibilities to their patient often preclude their use of safety devices such as seat belts. Research has shown that ambulances are more likely to be involved in motor vehicle collisions resulting in injury or death than either fire trucks or police cars. Unrestrained occupants, particularly those riding in the patient-care compartment, are particularly vulnerable. When compared to civilian vehicles of similar size, one study found that on a per-accident basis, ambulance collisions tend to involve more people, and result in more injuries. An eleven-year retrospective study concluded in 2001 found that although most fatal ambulance crashes occurred during emergency runs, they typically occurred on improved, straight, dry roads, during clear weather. Safety is thus of special concern in ambulance design.
Equipment
In addition to the equipment directly used for the treatment of patients, ambulances may be fitted with a range of additional equipment which is used in order to facilitate patient care. This could include:
- Two way radio – One of the most important pieces of equipment in modern emergency medical services as it allows for the issuing of jobs to the ambulance, and can allow the crew to pass information back to control or to the hospital (for example a priority ASHICE message to alert the hospital of the impending arrival of a critical patient.) More recently many services world wide have moved from traditional UHF/VHF sets, which can be monitored externally, to more secure systems, such as those working on a GSM system, such as TETRA
- Mobile data terminal – Some ambulances are fitted with Mobile Data Terminals (or MDTs), which are connected wirelessly to a central computer, usually at the control center. These terminals can function instead of or alongside the two way radio and can be used to pass details of jobs to the crew, and can log the time the crew was mobile to a patient, arrived, and left scene, or fulfill any other computer based function.
- Evidence gathering CCTV – Some ambulances are now being fitted with video cameras used to record activity either inside or outside the vehicle. They may also be fitted with sound recording facilities. This can be used as a form of protection from violence against ambulance crews, or in some cases (dependent on local laws) to prove or disprove cases where a member of crew stands accused of malpractice.
- Tail lift or ramp – Ambulances can be fitted with a tail lift or ramp in order to facilitate loading a patient without having to undertake any lifting. This is especially important where the patient might be obese. There may also be equipment linked to this such as winches which are designed to pull heavy patients in to the vehicle.
- Trauma lighting – In addition to normal working lighting, ambulances can be fitted with special lighting (often blue or red) which is used when the patient becomes photosensitive.
- Air conditioning – Ambulances are often fitted with a separate air conditioning system to serve the working area from that which serves the cab. This helps to maintain an appropriate temperature for any patients being treated, but may also feature additional features such as filtering against airborne pathogens.
Intermediate technology
In parts of the world which lack a high level of infrastructure, ambulances are designed to meet local conditions, being built using intermediate technology. Ambulances can also be trailers, which are pulled by bicycles, motorcycles, tractors, or animals. Animal-powered ambulances can be 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.
The design of intermediate technology ambulances must take into account not only the operation and maintenance of the ambulance, but its construction as well. The robustness of the design becomes more important, as does the nature of the skills required to properly operate the vehicle. Cost-effectiveness can be a high priority.
Appearance and markings
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 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.
Passive visual warnings
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Intensive Care ambulance with reflective markings.]]
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 retro-reflective designs which reflect light from car headlights or torches. Popular patterns include 'checker board' (alternate coloured squares, sometimes 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 reflective material, invented by 3M, only came in tape form). In addition to retro-reflective markings, some services now have the vehicles painted in a bright (sometimes fluorescent) yellow or orange for maximum visual impact. In Europe this colour is defined as Euro Yellow RAL 1016 for emergency service vehicles.
Ambulance displays reversed wording and star of life]]
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 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), such as a Red Cross, Red Crescent or Red Crystal (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, organization 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, 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 does not have recognition beyond Israeli borders, where they must use the Red Crystal.
The Star of Life is widely used, and 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.
Ambulance services that have historical origins in the Order of St John often use the Maltese cross to identify their ambulances. This is especially important in countries such as Australia, where St John Ambulance operate one state and one territory ambulance service, and all of Australia's other ambulance services use variations on a red Maltese cross.
Fire service operated ambulances may display the Cross of St. Florian (often, incorrectly, called a Maltese cross) as this cross is frequently used as a fire department logo (St. Florian being the patron saint of firefighters).
Active visual warnings
ambulance and response car displaying active visual warning beacons]]
The active visual warnings are usually in the form of flashing coloured lights (sometimes 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 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). The use of LED flashing lights is more common as they are low profile and low energy. See Emergency vehicle equipment.
In order to increase safety, it is best practice to have 360° 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 mandatory.
Audible warnings
In addition to visual warnings, ambulances can be 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.
Ambulance services may specifically train their drivers to use different siren tones in different driving situations. For instance, on a clear road the 'wail' setting may be used, which gives a long and steady up and down variation. At busy intersections, the a 'yelp' setting may be employed, which delivers a more rapid bursting signal. 'Dual tone' and 'phaser' modes are also available on many modern sirens. Changing the speed and pitch of the warning intensifies the alert delivered to drivers in the ambulance's path.
The speakers for modern sirens can be integral to the lightbar, or they may be hidden in or flush to the grill to reduce noise inside the ambulance that may interfere with patient care and radio communications. Ambulances can additionally be fitted with airhorn audible warnings to augment the effectiveness of the siren system.
A recent development is the use of the RDS system of car radios. The ambulance is 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 every RDS radio 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 audible warnings, as it is unable to alert pedestrians, or those not using a compatible radio.
Service providers
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Operational Command Vehicle]]
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 – 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 a national health system.
- Fire or Police Linked Service – In countries such as the U.S. and France ambulances can be 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. In some cases this can lead to an illness or injury being attended by a vehicle other than an ambulance, such as a fire truck.
- Volunteer Ambulance Service – Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service across the world on a volunteer basis. (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance and the Order of Malta Ambulance Corps. These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of Australia and in Ireland.
- Private Ambulance Service – Normal commercial companies with paid employees, but often on contract to the local or national government. Private companies may provide only the patient transport elements of ambulance care (i.e. non urgent), but in some places, they are 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. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility impaired if they have for example fallen and just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies.
- 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 may be found in smaller towns and cities, where size or budget does not warrant separate services. 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 – 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 dependent 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.
- Company Ambulance - Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehichles in the event of a fire or explosion.
Costs
The cost of an ambulance may be paid for from several sources, and this will depend on the type of service being provided, by whom, and possibly who to.
- Government funded service – The full cost of the ambulance is borne by the local or national government, with no cost a point of care. One example of this is in the United Kingdom, where ambulances are provided as of right, to anyone who requests one, with costs bourne centrally from taxation as part of the National Health Service
- Privately funded service – The ambulance is paid for by the patient themselves, or through their insurance company. This may be at the point of care (i.e. payment or guarantee must be made before treatment or transport), although this may be an issue with critically injured patients, unable to provide such details, or via a system of billing later on
- Combined system – Ambulances may be free of charge to those who cannot pay (such as those who receive government welfare payments), but chargeable to those who can afford it, or who are insured. It can be the case that a free government provided system may be charged for if the patient is not found to be in genuine need, or they already have insurance which covers them.
- Charity funded service – Ambulances may be provided free of charge to patients by a charity, although donations may be sought for services received.
- Hospital funded service – Hospitals may provide the ambulances free of charge, on the condition that patient's use the hospital's services (which they may have to pay for). In China, where this is the case, there have been reported incidents where a hospital which was not permitted to run an ambulance service illegally did so, in an effort to increase its business.
Crewing
There are differing 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. Generally this is a perjorative toward qualified Emergency Medical Service providers implying that they perform no function but driving.
- Ambulance Care Assistant – Have varying levels of training across the world, but these staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. Dependent on provider, they may be trained in first aid or extended stills such as use of an AED, oxygen therapy and other life saving or palliative skills. They may provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.
- 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 levels (such as in the US, where there is EMT-Basic and EMT-Intermediate).
- Paramedic – This is a high level of medical training and usually involves key skills not permissible for technicians, such as cannulation (and with it the ability to administer a range of drugs such as morphine), intubation and other skills such as performing a cricothyrotomy. Dependent on jurisdiction, Paramedic can be a protected title, and use of it without the relevant qualification may result in criminal prosecution.
- Emergency Care Practitioner – This position, sometimes called 'Super Paramedic' in the media, is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are already qualified paramedics who have undergone further training, and are trained 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.
- Registered nurse (RN) – Nurses can be involved in ambulance work, and as with doctors, this is mostly as air-medical rescuers or critical care transport providers, often in conjunction with a technician or paramedic. They may bring extra skills to the care of the patient, especially those who may be critically ill or injured in locations that do not enjoy close proximity to a high level of definitive care such as trauma, cardiac, or stroke centers.
- Doctor – Doctors are present on ambulances – most notably air ambulances – will employ physicians to attend on the ambulances, bringing a full range of additional skills such as use of prescription medicines.
Military use
M997 ambulance emblazoned with the Red Cross]]
of the French Army]]
, a U.S. Navy hospital ship]]
Military ambulances include both ambulances based on civilian designs 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 weapons, an ambulance AFV is unarmed. 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 —accidental or deliberate. As a result, medics and other medical personnel attached to military ambulances are usually put through basic military training, on the assumption that they may have to use a weapon. The laws of war 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 a number 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 disregard any symbols of protection and fire at ambulances anyway.
Some navies operate ocean-going hospital ships to lend medical assistance in high casualty situations like wars or natural disasters. These hospital ships fulfil the criteria of an ambulance (transporting the sick or injured), although the capabilities of a hospital ship are more on par with a Mobile Army Surgical Hospital. In line with the laws of war, these ships can display a prominent Red Cross or Red Crescent to infer protection under the appropriate Geneva convention, however, this designation has not always protected hospital ships from enemy fire.
See also
External links
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