Ambulances are emergency vehicles that are specially designed and equipped to provide for medical care and transport of patients typically in the recumbent position. In the United States, these are typically larger vehicles. Three main ambulance design types are prevalent and offer different advantages and disadvantages. Several ambulance standards exist, including those composed by the American Ambulance Association (AAA), the US General Services Administration (GSA): KKK-A-1822F, and the National Fire Protection Association (NFPA): 1917. EMS physicians must understand the differences in the basic ambulance types and should also take the time to review local, state, and federal standards. The ambulance types described below are based on industry common language and not representative of the “typed resources definitions” used by the Federal Emergency Management Agency (FEMA). These are briefly described later in this chapter.
A type I ambulance is built on a truck chassis and the patient compartment typically is shaped like a large rectangular box with a double door on the back and a single side door at the front of the right-hand side of the box (Figure 31-1). Because the patient care area is mounted on the truck chassis, there is typically only a very limited pass-through into the driver's compartment. The increased load-bearing capacity of this ambulance type allows for larger patient care areas and makes this type more ideal for complex critical care transport configurations. This type is also sometimes preferred by rural agencies who seek to equip their agency with four-wheel drive units or combination departments with the need to carry additional rescue equipment on their ambulance. The potential downside of the type I ambulance is that it may seem less maneuverable than other types. Some type I ambulances are very large and are based on trucks that more closely resemble construction vehicles rather than pickup trucks. These larger-scale type I ambulances are sometimes referred to as “additional duty” or “medium-duty” (Figure 31-2).
Type I ambulance. Photo depicts a type I ambulance used for critical care interfacility transport and for scene calls. Note the truck cab front.
Type IAD/MD ambulance. Photo depicts a type I ambulance used for pediatric critical care interfacility transport. This unit is based on a larger truck and is of the “additional duty” or “medium duty” class. (Reproduced with permission from Diane Cooney, RN.)
A type II ambulance closely resembles a full-size conversion van. Based on the standard full-size utility van, this type typically has an elevated celling in the patient care compartment to allow for enough room to load, unload, and provide care en route (Figure 31-3). Type II ambulances are relatively maneuverable and more economical. The smaller patient care area may limit their use in interfaculty transport and equipment storage can be limited, or at times quite awkward in some configurations. Some systems use them only for basic life support calls.
Type II ambulance. Photo depicts a type II ambulance and the relative constraints of the internal dimensions of the patient care area in this type. Backboards are stored under the bench rather than in an external compartment. (Reproduced with permission from Dr. Derek Cooney.)
A type III ambulance is similar in general appearance to a type I ambulance; however, they are based on a large van chassis rather than a truck (Figure 31-4). The van cab is maintained but the patient care area is a rectangular box similar to that of the type I. These typically have a lower load-bearing capacity than the type I. The customized patient care area is usually adequate to support all types of standard field and interfacility advanced life support operations. Due to the fact that this type is based on a van chassis, there is usually a larger pass-through into the driver's compartment from the back.
Type III ambulance. Photo depicts a type II ambulance in service with East Area Volunteer Emergency Services in East Syracuse, New York. Note the cab is that of a van rather than that of a truck. (Reproduced with permission from Dr. Derek Cooney.)
A type IV ambulance is a term used by some, but not all, members of the EMS industry to refer to ground ambulances that do not conform to the above configurations. These typically mean small motorized (gas or electric) vehicles that have been customized to service in carrying a stretcher and patient. Some examples include golf carts and four- or six-wheel off-road utility vehicles (Figure 31-5).
Type IV example: gas-powered mini-ambulance. Photo depicts a modified six-wheel off-road-capable utility vehicle (the Gator) used by Rural Metro Medical Services of Central New York for event medical coverage. This configuration has two provider positions to allow optimal patient care during transport of a patient on a standard EMS stretcher. (Reproduced with permission from Dr. Norma Cooney.)
Some other examples of vehicles used by EMS providers to reach acutely sick and injured patients include motorcycles and bicycles. Because of their speed and agility motorcycles are employed all over the world to provide various levels of EMS first response. Bicycle response is also an effective tactic to deliver care in crowded areas that are impossible to reach with a standard ambulance (Figure 31-6). Bicycle providers are typically utilized in mass gathering events and in heavily populated urban centers with limited roadway access. Bicycles and horseback-mounted providers are also found in remote wilderness locations and in larger public parks. EMS physician vehicles are discussed in a separate chapter on physician field response.
Bicycles equipped for EMS response. This photo shows “bike team” bicycles used by Rural Metro Medical Services parked at a mass gathering event in Syracuse, New York. These bicycles are equipped for ALS response.
FIRE AND RESCUE APPARATUS
There is a wide variety of fire apparatus configurations. Many departments operate custom-designed apparatus that may serve multiple purposes. Knowing the basic types and purposes may help the EMS physician understand on-scene operations better and allow for better placement of the EMS physician vehicle. This basic knowledge is also essential for physicians working with fire-based services.
Engine: The fire engine is the backbone of the fire service and is essentially a vehicle designed to deliver water to the fire scene and access additional water at the scene for the purpose of fighting fire (Figure 31-7). These typically carry their own hose and personnel, but may also come in as a single-purpose pump apparatus. Sometimes referred to as a “pumper” the fire engine is specifically not a fire “truck.” With reservoirs typically ranging from 500 to 1500 gallons and an outgoing pump capacity of around 120 pounds per square inch, the average engine will be out of water within 5 to 10 minutes and will need to have a supply line established with the hydrant system or portable ponds.
Fire engine. This engine carries its own hose supply. (Reproduced with permission from the City of Oswego Fire Department, Oswego, New York.)
Truck: A fire truck is actually a very valuable utility vehicle that delivers hydraulic pumps and tools, hand tools, power tools, saws, lights, fans, ground ladders, and other rescue operation and fire ground “truck company” equipment and personnel.
Ladder truck: This type of apparatus is a more specific type of truck that carries a large hydraulic latter, or aerial, on top (Figure 31-8). These usually have no water, but typically have a waterway that allows for water to be sprayed from the top of the aerial during a rescue operation or fire attack. They come in different forms such as turntable, tower, tiller, hydraulic platform, and aerial ladder platform types. In addition to the “snorkel” ladder on top that may reach around 100 feet, these trucks usually come loaded with many ground ladders. Not all departments can afford to operate this type of apparatus.
Ladder Trucks. (Reproduced with permission from the City of Oswego Fire Department, Oswego, New York.)
Rescue: The rescue type of apparatus is designed to carry and deliver rescue equipment and personnel and may be common to roadway responses. Some rescue vehicles are based on large pickup truck chassis with a custom equipment box and may have hydraulic tools and scene lighting as well as vehicle stabilization equipment. Heavy rescue vehicles are larger and carry more elaborate loadouts. When an engine is configured to provide rescue operations as well, it is often referred to as a “rescue pumper.”
HAZMAT/special ops: Specialty vehicles for hazardous materials response, disasters/MCIs, specialized rescue (high angle, swift water, SCUBA, etc) may take the form of a number of different configurations a vehicle types. These are typically large to accommodate the specialty equipment they deliver. Some resemble a heavy rescue while others may be based on a “bread truck” or “moving van”–type vehicle (Figure 31-9).
“Moving van–type” special operations vehicle. This vehicle operated by the City of Oswego Fire Department delivers special operations equipment of a wide variety. (Reproduced with permission from the City of Oswego Fire Department, Oswego, New York.)
Tanker: Some fire scenes are more rurally located or are in areas of a municipality known to have an aged or less reliable hydrant system. Tankers carry large volumes of water and can typically be drafted from, lay down a portable reservoir, or pond, and in many cases can be used to go on runs to natural water sources to refill and return to dump water into the portable ponds.
Quint: These combination role apparatus are designed to fill the roles of an engine, truck, and ladder truck. The five incorporated elements that make this type a “quint” are the fire pump, water reservoir, hose storage, ground ladders, and an aerial ladder. These are popular in some smaller departments; however, there is significant controversy over their true utility, as they sometimes perform each role to a lesser degree than a dedicated apparatus might. They typically carry the same personnel count and can only engage in one function until additional firefighters arrive.
Wildland truck: This varies in size and configuration, but many times are based on a pickup truck with the ability to “chase” the fire as it moves across a field or other wildland. These vehicles typically care some a small water supply and a coiled hose reel. These are also known as brush truck or grass truck.
Squad: A squad or “mini” is a smaller piece of apparatus and may have almost any function in the department. Some are for delivery of personnel and limited equipment, while others may even be equipped with a smaller fire pump.
Fly cars: A “medic car “or “MICU” may also be designated for first response medical operations. These can take many forms. EMS physician vehicle design is discussed in a separate chapter.
Boats: Some departments have a boat, or marine unit. These can range from inflatable zodiacs for water rescue, to rigid haul craft for operation in larger bodies of water. Some departments also operated pump boats for firefighting. Recently, some departments have begun to use personnel water craft for rescue operations.
Air medical transport is typically broken into aircraft type. Rotor wing refers to helicopter transport and fixed wing refers to airplanes. EMS physicians should be familiar with the safety and operation constraints of these vehicles, even if they do not provide care and transport in an air medical environment. Air medical transport is discussed in a separate chapter.