EMS in The Netherlands: A Dutch Treat?

In the 17th century, the place we now know as”žNew York City was called”žNew Amsterdam. Founded by Dutch merchants to start trade, the place was named after the Dutch capital. This Dutch influence in the Big Apple is still present. Old Dutch city names remain, including Flushing, Harlem and”žBrooklyn.”žNew York has become a world capital. And what about the Dutch?

This article will provide a renewed acquaintance with the people who many assume to live between tulips. And how do you drive an ambulance wearing wooden shoes?

Brief history

Europe has a rich history with the Ë™transport of the sick and injured.à“ In the 18th century,”žVienna,”žAustria, had an organized service comparable to a true”žEMS system.”žHolland has the same tradition. Before the invention of the automobile, patients were collected by organized horse-and-carriage services, mostly municipal services.

From the moment the automobile was available, the services transferred from horse-drawn carriages to ambulances. This development continued but was disrupted by the second World War. After the war, ambulance services resumed, then using abandoned Allied vehicles.

In the cities, municipal health care organizations managed”žEMS as a third service. Outside the cities and in the villages, ambulances were operated from private corporations, such as local taxi or automobile dealers and garages. A difference in the quality of care was noted. Ambulances from the municipal services were staffed by nurses. Local village ambulances were staffed with merely first aid personnel.

In the 1960s, ALS equipment became available for ambulances, including monitor/defibrillators. In the ’70s and ’80s, developments increased. Self-respecting private ambulances changed from first aid personnel to nurses. By the mid 1980s, 99% of all Dutch ambulances were staffed by nurses. In 1988 the National Ambulance Education Foundation was founded. In 1992, a law stated that all ambulances in The Netherlands must be staffed by a nurse.

The Foundation later became the Dutch Ambulance Institution, which provided rules and regulations concerning labour conditions, protocols, education, equipment and even the appearance (uniforms and vehicle striping) of”žEMS and its personnel.


A major train crash in 1962 revealed that”žEMS lacked organization, cooperation, negotiation and dispatch. From that moment on,”žEMS enforced by law was introduced. What started as a reorganization of EMS in 1962 has now become a dedicated and truly professional system in which”žEMS flourishes.

Holland has a high standard of health care. Every Dutch citizen has the obligation to be insured for health care. Low income citizens and unemployed people are provided with health-care insurance by the National Health Trust.

Part of the health-care system is that everybody who needs medical attention will visit their personal general physician (GP), the house doctor or family doctor. The GP is, therefore, the gateway to clinical health care provided by hospitals. In case of a medical emergency, the patient can call for an ambulance by dialling the (European) emergency number 1-1-2. Emergency dispatch can decide if the emergency is of a nature that does not require”žEMS or hospital interference. If so, the patient_s GP will be informed or the patient is asked to contact their GP. In any case of doubt, an ambulance will be sent.

All over The Netherlands, 195 ambulance stations operate a total of 650 ambulances. Due to the”žEMS reorganization as mentioned, The Netherlands are divided into regions. In a region, one or more ambulance services can operate. At the time of writing,”žHolland has 15 regional ambulance providences in which 45 ambulance services operate. By law, a dispersion of ambulances must guarantee that an ambulance will be on scene within 15 minutes after an emergency call anywhere in the country.

Dispatch is also organized per region, meaning that one dispatch center handles all calls for emergency and non-emergency transport in the whole region. Regions differ in size, depending on the number of people living in each area.

The Dutch health-care system includes three types of ambulance response. The first one is the emergency response, coded A1, in which the ambulance immediately responds using lights and siren.

In cases without serious life threat and the patient is relatively stable with a GP present, an ambulance can be requested as an A2 emergency. For an A2 call, the ambulance will commence immediately but without lights and siren, which is much safer for the crew and causes less disturbance in the community. The ambulance must arrive within 30 minutes after an A2 call.

If a patient needs to be admitted to a hospital or needs medical attention during inter-clinical transport, an ambulance is requested with a so-called B emergency (non-emergency).

In 2004,”žEMS responded to 341,000 A1 emergencies, 153,000 A2 emergencies and 313,000 B emergencies.

The macro budget for”žEMS in 2004 was à–”ž293 million”ž(approximately”ž346 million U.S. dollars).


Dutch health-care personnel are also divided into levels. In the case of an emergency, first responders are available; depending on the situation, these responders are trained in first aid and are mostly police officers and occasionally firefighters. Other emergency personnel include GPs,”žEMS and hospital care providers. Each group of caregivers has its level of skills and knowledge and know when to hand over care to another entity.

A major difference between a Dutch ambulance crew and those in other countries is the strict separation in the scope of duties. Every ambulance includes a crew of two. One is the nurse, skilled and trained in medical issues, procedures and performances. The other crew member is the driver, trained in vehicle operations for all circumstances. The driver also assists the nurse but does not interfere with any medical issues.

Dutch EMS consists of 1,400 ambulance nurses, 1,240 ambulance drivers, 330 dispatchers and 330 other personnel/staff.

A special service is provided by 10 level-1 trauma centers, mostly university hospitals. They send out a mobile medical team (MMT). An MMT consists of a resident surgeon or anaesthesiologist and a nurse. The team is available around the clock and can be requested to perform medical actions that exceed the possibilities of the on-scene ambulance nurse. Inserting chest tubes, performing anaesthesia, including muscle relaxation (narcosis), administering advanced analgesia and performing amputations are a few examples of the MMT capabilities. The request of an MMT can be criteria-based dispatched, depending on the call.


As identified earlier, the main medical care provider on an ambulance is a nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment.

Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses.

After becoming a registered ambulance nurse, post initial training and educational programs are also mandatory. One of the required programs is the NAEMT Prehospital Trauma Life Support Course. Nurses are trained in the PHTLS program on an advanced level, and drivers are trained on a basic level.

Continuing education is organized on two levels: national and regional. The mentioned PHTLS courses are in the national program, as well as special paediatric courses. For regional education, a wide scale of topics are available and held in smaller groups, mostly at ambulance stations. A number of appointed and licensed training institutes carry out the educational programs.

Doctors in an MMT have also had additional training to prepare them for the prehospital setting. For example, extra courses in extrication techniques are required. A nurse participating in an MMT is a senior ambulance nurse and has taken the same additional training as the MMT doctors.

This level of training and education allows ambulance nurses to work on a rather independent and self-supporting basis. If an ambulance crew encounters a situation that aren_t within their protocols, procedures or standing orders, providers can contact the medical manager of the ambulance service. If medical procedures must be applied that are beyond the possibilities of the ambulance nurse, providers can request for an MMT.

All procedures are brought together in the National EMS protocols. These protocols are revised or adjusted every four years. Within these protocols, ambulance nurses are allowed to administer 31 different types of medication.“ž (See Table 1.)

Ambulance nurses are also allowed to carry out many medical procedures, including”žthrombolysis, which is practiced on a common basis. The drug in use depends on the region of the ambulance service. In the case of thrombolysis, providers select the medication after deliberation with the admitting hospital staff.


All ambulances in The Netherlands are equally equipped. Aluminium cases are stocked with medical appliances, such as syringes and medication. Other materials, such as scoop stretchers, backboards, splints and collars, are also stocked. All vehicles are equipped to perform both BLS and ALS, with enough supplies on board to treat three patients on scene in case of an MCI (depending the extend of care they need).

All ambulances carry 12-lead ECG equipment, a monitor/defibrillator, a ventilator, infusion pumps and pulse oximeter.

For communication, mobile radios are mounted inside. Every ambulance carries a cell phone as well.

Especially in major cities with a medieval inner city, speed-lowering obstacles are commonly built in the road. Old inner cities are accessible for only pedestrians and cyclists, with the exception of”ž”ž emergency vehicles. To enter such an area, emergency providers carry several remote controls and special keys to bypass the mechanical obstacles, such as rising steps.

All ambulances are equipped with a tracking system so dispatch can locate them and control their status. A digital routing system is also present in all ambulances, which is handy when in small villages and narrow inner city streets.

For recognition, all ambulance personnel are dressed in blue and yellow uniforms. Helmets are present on the ambulance. In case more ambulances need to respond to a scene, the first arriving ambulance starts the incident management and identifies themselves by wearing green vests and by flashing or rotating a green light on their ambulance. All arriving crews can easily identify and respond to the first arrived crew. MMT personnel can be recognized by their red and yellow uniforms.

Patient data in the ambulance are gathered and digitally processed by handheld computers.


In the 1950s, emergency vehicles acquired lights and sirens. In those days, the Dutch police and fire departments received more respect from the public than”žEMS did. To make that distinction clear, ambulances were given a different siren. Police and fire departments use a two-tone horn, and ambulances use a three-tone horn. This difference remains today.

Emergency vehicles in The Netherlands carry blue rotating or flashing lights. The one exception is the green light for the first arriving crew in a multiple-unit response, as described.

In The Netherlands, the same development in vehicle building was seen as in the”žUnited States. Because of the increase in equipment carried on board, ambulance expanded from the limousine-like ambulances in the 1960s to the van types of later date.

Many cities still maintain a medieval city center (the old town). Cosy but narrow streets are usual, which makes it impossible to use large vehicles or trucks.

Even in current days, ambulance are built on limousine chassis, mostly Mercedes Benz. One Dutch builder, the Visser-company, has its own distinctive design.

Every ambulance service is allowed to choose its own type of ambulance from one of three ambulance builders. Manufacturers build ambulances on Mercedes Benz (for vans and limousines) and Ford Ecovan or Chevrolet on a regular basis. If requested, ambulances can also be built on cars, such as Volvo, Fiat and Volkswagen. Other ambulances are imported from manufacturers in various countries, mostly”žGermany and the”žUnited States.

In the past 10 years, emergency services have been cooperating, founded on laws regarding disaster relief. To become more distinctive and yet more recognizable, the emergency services all carry the same striping. One major difference is the background color. Police vehicles are white with blue and red striping, fire trucks are red with white and blue striping, and ambulances are yellow with blue and red striping. The striping is found on all emergency vehicles, from motorbikes to helicopters.

In response to the large amount of traffic congestion, a rather new development is”žEMS motorcycles. They are stocked like first responder units, carrying enough equipment to start ALS while waiting for an ambulance to arrive.

The MMTs are all equipped with a van that contains additional medical equipment. Four MMTs also have the disposal of a helicopter, called Lifeliners. They_re based in the cities of”žAmsterdam,”žRotterdam,”žNijmegen and”žGroningen. For the past 10 years, the helicopters flew only during daylight, but they are expected to start night flights very soon. Also, in poor weather conditions that prohibit air transport, MMT vans are used.

The helicopters, each with a flight radius of only 45 miles, cover approximately 80% of Dutch soil. The remaining 20% is covered by helicopters from”žGermany and”žBelgium. With the arrival of an MMT, additional medical specialists and medical treatment are available on scene. The helicopter is basically for the transport of the team; transport of the patient is done in most cases by the ambulance, with the MMT doctor present to treat the patient during transport.

Disaster Relief

Due to several large scale incidents and the increasing population, disaster relief has been a major point of interest since 1992. That year, the Department of Home Affairs released the Law on Disaster Medicine. It was contemplating the organization of a Medical Disaster Control System, aiming for the creation of a functional organization for emergency medical care that guarantees upstaging from routine to effective disaster medical care.

With this plan came the assignment of 10 major hospitals to provide an MMT. It also implemented so-called medical combinations. And within 25 regions, regional medical commanders were made responsible for disaster relief.

Carrying out the plans meant that not only should the disaster be organized, but it should be controlled. This plan involves all emergency services.

We now recognize four different levels of mass casualty incidents, all being Coordinated Regional Incident Control Procedures. For each level, a higher authority is in charge.

When a procedure starts, daily routine is upscaled. Officers in charge are added, and a medical combination is added from the second or third level, depending of the nature of the incident. A medical combination is the cooperation of a double ambulance crew arriving in a special vehicle equipped for medical treatment of up to 30 casualties, a team of The Red Cross to carry casualties, and an MMT.

In The Netherlands, most of the Regional Medical Disaster Control Systems are operational. The government has stated a budget that allows training, exercise and knowledge development.


Like most other Western countries, The Netherlands are well developed in health care and”žEMS. On Dutch ambulances you find a well trained and educated team, with separated tasks for each member of the crew. By having prehospital providers working in conjunction with house doctors on one side and MMT doctors on the other side, the patient can receive optimal care. In the chain of emergency care, Dutch EMS is certainly not the weakest link.

Dennie Wulterkens”ž is an ambulance nurse and paramedic, as well as the vice chair of NAEMT International Division.

Table 1: List of medication on Dutch ambulances

  1. Acetylsilicyt acid
  2. Adenosine
  3. Amiodaron
  4. Atropine
  5. Biperideen
  6. Budenoside
  7. Butylscopolamine
  8. Clemastine
  9. Denilox
  10. Dexamethason
  11. Diazepam
  12. Diclofenac
  13. Epinephrin
  14. Esketamine
  15. Fentanyl
  16. Furosemide
  17. Glucagon
  18. Glucose
  19. Haloperidol
  20. Ipratropiumbromide
  21. Magnesium sulphate
  22. Metoclopramide
  23. Morfine
  24. Naloxon
  25. Nitroglycerine
  26. Oxytocine
  27. Plasma substitution”ž
  28. Ranitidine
  29. Salbutamol
  30. Sodium Bicarbonate
  31. Xylometazoline”ž

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