The transport of the wounded has always existed in history, by the strength of arms or by horse-drawn vehicles in Antiquity and the Middle Ages. However, at that time, there were no specific standards or training on the means used, the training of the people who were responsible for it, and even less on the care of the wounded. The oldest traces of treatment on the wounded seem to date back to the Neolithic period : skulls trepanned to reduce intracranial pressure as well as skeletons bearing traces of amputation have been found in Brittany, a region of France. Ancient Egypt also had doctors trained in emergency care and medical treatises written as evidenced by papyri found by archaeologists. Emergency medicine also developed in ancient Greece, especially in armies where soldiers were specially trained to stop bleeding and provide first aid. The Roman Empire also had mobile hospitals valetudinarium that accompanied armies on the move. The collection of the wounded was generally carried out by local civilians paid according to the number of soldiers recovered. Later, the Romans trained non-combatant health auxiliaries for the evacuation of the wounded. In the Middle Ages, the care given to the wounded on the battlefield became secondary, and their fate was generally to be finished off by the victor despite some local initiatives, often led by religious orders.

The first real "ambulance" service is considered to have appeared during the siege of Málaga in 1847 when the Spanish used a relatively organized and structured service to evacuate their wounded to field hospitals. An improvement was made in France by the chief doctor Dominique Jean Larrey, who had carts large enough to allow the transport of the wounded in good conditions after they had received first aid in the field. This last point is a real innovation that greatly reduces the mortality rate. These "flying ambulances" were used for the first time by the Army of the Rhine in 1793. The American Civil War from 1861 to 1865 saw several improvements made. The first four-wheeled vehicles appeared, while the care provided in the field was more efficient and boats and trains were used for the first time to transport the wounded.

In the civilian field, it would seem that the first organized services appeared in London in 1832 to transport cholera patients. In the United States, it was the Commercial Hospital in Cincinnati that was the first to install an ambulance service in 1865, quickly followed by the Bellevue Hospital in New York. The ambulances are becoming more sophisticated and comfortable for patients, and also carry the necessary equipment for on-site patient care, such as first aid kits, morphine, splints and brandy. The first horns also appeared : a bell that the coachman operated with his foot allowed the ambulance to signal itself.

The beginning of the 20th century saw the appearance of the first motorized ambulances. First electric motors started in 1899 in Chicago and then in New York. But the more powerful internal combustion engine took over in 1905 in Canada before gradually becoming widespread. In 1909, the first mass-produced combustion engine ambulances were produced in Rochester, New York.

The First World War led to a rapid development of ambulance services, which were often provided by women who learned the trade "on the job" while the vehicles became more sophisticated. Once the war is over, some of the ambulance drivers will resume their civilian activities by passing on their knowledge and experience. However, there is still no civilian ambulance school and learning is mainly done in the field or through charitable and privately funded organizations. Military ambulance services continued to develop during the Second World War, but here again, the changes mainly concerned the armies for the evacuation of soldiers, the civilian world being little concerned.

The next big change did not come until 1952, following the railway disaster between the English towns of Harrow and Wealdstone. Similarly, the sharp increase in post-war civilian road traffic led to a sharp increase in road accidents, requiring an appropriate response. Ambulances are becoming mobile places of care capable of carrying a wide range of medical equipment, including defibrillators. The first standards in the design of ambulances were enacted, whether it was the minimum equipment on board or their dimensions. Logically, the appearance of vehicles changes radically as they become larger and heavier. The training of crews is also reviewed and begins to be professionalized, even if it is still limited to basic first aid. In 1967 in the United States, the Freedom House ambulance service in Pittsburgh was the first in the world to provide truly advanced and specific training. In other countries such as France, professionalization only really began in the early 1970s with standardized, compulsory training leading to an official diploma.

The design of ambulances has changed enormously in a few years. Ambulances derived from "tourist" vehicles such as station wagons (Citroën DS in France or Cadillac Meteor in the United States for example) were unable to support the weight of the new equipment and gradually disappeared. Ambulances are now installed on the chassis of vans or light trucks, the only ones capable of providing sufficient interior space and supporting a complete care module. Particular attention is beginning to be paid to ergonomics and comfort, as well as to radio communication equipment and sound and light horns. Similarly, equipment that facilitates driving is becoming widespread and is now essential.

Today, the design and construction of ambulances is the responsibility of specialized companies that also take care of their maintenance.

An ambulance can be defined as « a vehicle specially adapted, fitted out and equipped to, on the one hand, offer urgent assistance at the scene of an intervention and, on the other hand, allow the safe transport of a sick or injured person or a woman about to give birth to a hospital or a specialized care unit. The ambulance has the necessary equipment for surveillance and first aid. »

From now on, ambulances must comply with precise regulations issued by the services of each country. This regulation starts by covering the external appearance of the vehicle, which must generally include flashing lights, sirens, specific markings such as a specific reflective paint, an ambulance identification number, the department's call number, the medical symbol, etc. These standards may vary from country to country, but are often more or less shared.

Technically, an ambulance can be based on different types of vehicles depending on the needs. The lightest ones fitted out from a van are close to 3.5 tonnes, while the heaviest ones, which consist of a care module resting on a light truck chassis, can reach up to six tonnes. Depending on the country, ambulances can be classified into different categories according to their uses. In France: category A (Emergency care), B (Assistance to the milder injured) or C (Transport of patients who do not require care, for a transfer for example). In the United States, we speak of Type I (the heaviest), Type II (lighter, based on heavy vans), Type III (intended for rescue) and Type IV (designed to operate in dense environments, such as a crowd).

The engines are based on petrol or diesel engines. Projects aimed at installing electric motors have already been launched, but are far from being generalized due to the constraints (range, charging time, etc.) of this motorization. The gearbox is generally an automatic transmission, much more suitable for driving a heavy machine and often having to move in traffic. Other equipment that facilitates driving (anti-lock braking systems, traction control, reverse parking assistance, etc.) or comfort (air conditioning, heating, etc.) are widespread on contemporary ambulances. The driver also has a GPS to guide him, which can sometimes be coupled with a short messaging system (Short Data Service) in order to update the information received. Depending on the country, services, regulations or budgets, ambulances may be equipped with additional equipment such as a "black box" in the event of an accident.

The "decoration" of ambulances has also changed significantly over the decades. Long left to the convenience of the user companies, the livery of ambulances is now heavily regulated : colours, inscriptions or markings are generally defined by strict regulations. It usually includes reflective bands and an easily visible main color, even if white is still often used in France in the SAMU (Emergency Medical Assistance Service). The markings include emergency call numbers, the AMBULANCE inscription accompanied by the name of the service (hospital, fire brigade, private company, etc.) or the vehicle identification number. In the early 1970s, the International Red Cross filed a lawsuit against the use of its logo on ambulances, which until then had been used to identify them. Faced with the ban on the use of the red cross on ambulances that did not belong to the organization, Leo Schwartz of the National Highway Traffic Safety Administration designed a new logo : a six-pointed blue star with the staff of Aesculapius surrounded by a snake. The Star of Life was born. It quickly became widespread and even became compulsory in France in 1979.

Another development in recent decades is visual and audible warnings. The flashing red headlights are quickly replaced by rotating or intermittent blue flashing lights. For example, France imposed the flashing light in 1964, becoming a pioneer country on this subject. Horns are also being improved and standardized, with two or three-tone bells and a decibel volume that is higher than the ambient traffic noise but lower than that of pain. It should be noted that the American services use more intrusive sound systems than their European counterparts. American ambulances are often equipped with a vibrating bell (Rumbler or Howler) that are designed to be felt more than heard.

The interior design of ambulances has obviously undergone enormous changes since the beginning. Today, the cubicles are large enough to allow the care staff to stand up in order to facilitate their work. The interior space can accommodate a patient in a lying position as well as an ambulance driver and sometimes a doctor in the countries where they are part of the crew. Logically, the medical unit is specially equipped and sized to carry important care equipment that is often subject to regulations. In France, for example, the medical kit must include portable oxygen, a stretcher, the necessary for artificial ventilation, a blood pressure monitor, a defibrillator or various dressings, splints and cervical collars. Cabinets and drawers arranged in the medical cell allow the equipment to be stored in a relatively small space. From the design stage, the medical cabin is designed to be easily cleaned and disinfected after each operation. A sound insulation system ensures the comfort of the patient and medical staff, while air conditioning keeps the temperature of the cell between fifteen and thirty degrees.

Legally, an ambulance driver (or Paramedic in some Anglo-Saxon countries) is a health professional who works in a private medical transport company or a health care establishment. His role is to ensure the care of the injured person and his transport to a medical facility. Its formation logically varies from one country to another, or even from one state or region to another within the same country. For a long time, the ambulance driver had no specific training, the profession being learned "on the job" in contact with experienced colleagues who passed on their knowledge to the young recruits. Medical transport could be provided by the hospital itself or by independent providers who purchased a vehicle, had it modified by a specialist and registered as ambulance drivers with the authorities without any specific diploma being required. The profession really became more professional from the end of the 1950s in some countries, while it was not until the end of the 1960s or the beginning of the 1970s in the United States or France.

In the United States, all paramedics must meet training standards set by the National Highway Traffic Safety Administration which sets specific training. Subsequently, each state in the country can add its own standards and requirements. As a result, the training of an American paramedic can last between six months and four years depending on whether the candidate takes specific diplomas after his basic training. In all cases, paramedics must undergo a training and refresher program throughout their careers in order to maintain their skills and acquire new ones.

In Canada, the Paramedic Association of Canada sets the minimum standards for four areas : Emergency Medical Responder, Primary Care Paramedic, Advanced Care Paramedic and Critical Care Paramedic. Quebec has a slightly different system, paramedic training is obtained through a three-year college diploma in pre-hospital emergency care, including more than 2,000 hours of technical training. In Australia, it is a three-year bachelor's degree in paramedicine in specialized faculties that qualifies a paramedic who is then registered with the Paramedic Council of Australia through the Australian Health Practitioners Regulatory Agency. It is then possible for the paramedic to specialize in intensive care or general care with a master's degree.

In Europe, the reality varies from country to country. In Germany, the training is governed by the Principles for the Training of Personnel in the Emergency Services of the Federal Committee of the Länder Rettungswesen and includes a minimum of 520 hours of lessons. In France, ambulance drivers are state-certified ambulance auxiliaries or ambulance drivers. The paramedic receives 91 hours of training in a specialized centre and is responsible for driving the vehicle. The state-certified ambulance driver follows a training course of about 18 weeks in an ambulance training institute, including 5 internships and must validate various medical skills modules. The diploma is sanctioned by the prefect of the region. The Swiss system is quite different. It has two levels. The Higher School Ambulance Diploma is obtained in three years and allows you to take care of a patient, even if seriously injured, in a complete and autonomous manner. Finally, the Ambulance Technician with a federal certificate can provide the same care, but under the responsibility of the Higher School ambulance driver: injection of medication by infusion, electrocardiogram (ECG), ventilation, etc. The certificate is obtained after one year of training. There are currently seven training centres for ambulance drivers in Switzerland.

Several books helped me write this guide.

• BARDET Romaric. Ambulanciers : La mémoire oubliée Les ambulanciers à travers l'Histoire. Editions L'Harmattan
  
• LAVIRON Daniel. Ne tirez pas sur l'ambulance (Tomes 1 et 2 ). Hello Editions
  
• VIAU Martin. Un dernier tour d'ambulance Récits d'un paramedic. Les Editions du journal
  
• VIRENQUE Christian. L'hélicoptère sanitaire. Guide de la médecine héliportée. Cépaduès Editions

As well these websites.

• Ambulancier-lesite.fr
  
• SwissRescue.ch