Ambulances, in various forms, have existed since mankind indulged in war. The instinct to save lives, to reach a healer in time, is as old as civilisation itself.
Modern ambulances, however, are a product of the industrial revolution, shaped by better automobiles and advances in medicine, especially trauma care. The two World Wars, as well as the Korean and Vietnam wars, became great teachers in emergency medical response. War brought not only destruction but also discipline, the precision of rapid evacuation, organised triage, and timely resuscitation. These hard lessons laid the foundation for what we now know as modern emergency medicine.
‘Platinum Ten Minutes’
The idea of the ambulance is grounded in the science of human physiology. Acute illnesses, especially trauma, trigger sudden circulatory and pathological disturbances that can quickly turn fatal. Prompt diagnosis and intervention can reverse such pathological disturbances and restore normalcy. Delayed treatment leads to irreversible pathological changes in major organs, often resulting in preventable mortality. Hence, the ‘Golden First Hour’ concept is now universally accepted not just in trauma care but in heart attack and stroke cases too. It has evolved from quick transport from the site of the accident to starting treatment right from the accident site, and continuing treatment while transporting the patient to a hospital.
Today, most ambulances are equipped to deliver oxygen, start intravenous fluids, secure the airway, manage breathing, including intubation and intercostal drainage, and control bleeding. Many are fitted with defibrillators, ECG and ECHO machines, and some even carry mobile CT scanners which allow early stroke diagnosis and treatment during transit. Deliveries can be conducted if necessary, and the new-born can be stabilised until the ambulance reaches the hospital. From the golden hour, the world is now moving towards the ‘Platinum Ten Minutes’ standard — the goal that medical help, not just an ambulance, should reach the victim within 10 minutes. Many countries aspire to this, though challenges remain, including difficult terrains, remote areas, war zones, extreme weather, and overcrowding during mass events. The ‘Platinum Ten Minutes’ is not a slogan but an ethical responsibility that defines how a society values human life.
Operational challenges
Broadly, there are two models of ambulance care. One is manned by paramedical personnel trained in basic life support, and the other is led by doctors, where the ambulance functions as a mobile hospital. India follows a mix of both. The success of either model depends not only on technology but also on the training, motivation, and coordination of the people involved in it.
However, there are many technological and operational challenges. Ambulances require special designs to safely use oxygen and other inflammable gases. They must remain in good condition, be strategically placed, and be driven by trained drivers who can move fast without causing accidents, which are not uncommon. Health workers or nurses must be skilled to handle critical patients, make quick decisions, and act effectively in a moving vehicle. A central call centre with GPS is essential to identify the nearest available ambulance, estimate travel time, alert hospitals, and ensure readiness of medical personnel, blood, and ventilators. Facilities for live communication with specialists, image transmission, and real-time guidance can save crucial minutes during resuscitation. In many advanced systems, the hospital team monitors the patient’s vitals even before arrival. India has the talent to do this; what we often lack is a system that ensures it every single time.
The National Ambulance Code (AIS-125), mandated by the Union government, standardises the design, construction, performance, and equipment of ambulances. The Motor Vehicles Act, 1988, and its 2019 amendments, provide the legal basis for granting ambulances the right of way. The demands of the ambulance vary from transporting a stable patient to transporting one who requires advanced life support. The design and staffing of the vehicle varies accordingly and the call centre should be able to decide which type of ambulance would be appropriate for each emergency call.
The need to standardise
In India, while the National Health Mission provides crucial financial and technical support to States, the States have flexibility in implementation. This leads to a disparity in the quality of service across States. For the record, the State-run 108 Ambulance service is one of the most successful examples of public-private partnerships. About 10,000 ambulances are deployed in the country transporting between seven to nine million patients a year. Tamil Nadu is one of the best performers. It has a fleet of 1,353 strategically placed vehicles. The average response time in Tamil Nadu is 10 minutes and 14 seconds — almost reaching the internationally recognised ‘Platinum Ten Minutes’ standard.
However, apart from the State-run 108 service, private ambulances operate in most States with little standardisation of services. There is a need for a central organ to oversee, regulate and standardise all emergency services across States and Union Territories including air ambulance and drone services which may become critical vehicles for transporting life-saving organs for transplantation. There is a need for a uniform syllabus, certification and periodic drills for all those who are involved in rescue missions. Skilled personnel are not so easily available in rural areas and attrition rate is quite high even in cities. The lack of a uniform pay structure, promotion opportunities and high levels of stress preclude even interested persons, including medical personnel choosing this field. More often, private ambulances owned by small hospitals lack qualified personnel and equipment.
It is high time that every State establishes an Emergency Services Regulatory Authority to ensure that ambulances serve the purpose of saving lives and not just transporting patients.
A constitutional duty
But even the best ambulance is of little use if it cannot reach the site of a disaster. This has been witnessed repeatedly during large public gatherings. The recent stampede in Karur, Tamil Nadu, is one such grim reminder. Though ambulances responded promptly, they could not enter the scene due to chaos and blocked routes. This is not new, for similar tragedies have unfolded time and time again. Every time, we mourn and move on, without fixing the basics.
The State has a duty towards its citizens. The right to life includes the right to emergency medical care. No mass gathering should be permitted without ensuring unobstructed entry and exit routes for ambulances. This should be non-negotiable. Events should not extend beyond a few hours, as most deaths occur due to dehydration and compression asphyxia rather than the stampede itself. People can suffocate even while standing, crushed by the crowd around them.
The State must deploy well-trained and certified paramedical staff or volunteers, identifiable by uniform, within such gatherings, equipped with basic emergency kits. Immediate on-site cardiopulmonary resuscitation can save many lives; it is a proven intervention. The ‘Platinum Ten Minutes’ standard starts the very moment disaster strikes. Every passing minute decides the line between life and death.
A nation capable of performing advanced organ transplants and robotic surgeries cannot afford to lose lives to preventable tragedies like stampedes. Our ambulance services must be standardised, regulated, and integrated, including air and drone ambulances, with fresh standard operating procedures drawn up at the earliest. Tamil Nadu, with its very rapid response time, must come out with a Comprehensive Standard Operating Procedure at the earliest. The time has come to treat emergency medical response not as a service but as a constitutional duty. In the end, the true measure of a health system is not how many hospitals it builds, but how quickly it reaches the injured when every second counts.
Dr. J. Amalorpavanathan is member, Tamil Nadu State Planning Commission and a vascular surgeon involved in trauma care. Views are personal.