Emergency medical services in the United States
common_name = United States
capital = Washington, DC [cite web|url=https://www.cia.gov/library/publications/the-world-factbook/geos/us.html|title=All facts unless otherwise cited are from: The CIA World Fact Book|accessdate=2008-10-06]
area_km2 = 9826630
population_estimate = 303,824,640
population_estimate_year = July 2008
population_density_km2 = 30.91
healthcare = Private
Emergency Medical Services in the United States, (herein, "EMS)" provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the federal government, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual
stategovernments, which often require higher standards from the services they oversee.
Wide differences in
population density, topography, and other conditions can call for different types of EMS systems; consequently, there is often significant variation between the Emergency Medical Services provided in one state and those provided in another.
Organization and Funding
EMS delivery in the US can be based on various
models. While most services are, to some degree, publicly-funded, the factor which often differentiates services is the manner in which they are operated. EMS systems may be directly operated by the community, or they may fall to a third-partyprovider, such as a private company. The most common operating models in the U.S. include:
In one of the more common publicly-operated models, an EMS system is operated directly by the municipality it services. The services themselves may be provided by a local government, or may be the responsibility of the regional (state or provincial) government. Municipality-operated services may be funded by service fees and supplemented by
property taxes. In many such cases, the EMS system is considered to be too small to operate independently, and is organized as a branch of another municipal department, such as the Public Healthdepartment. [cite web|url=http://www.co.monterey.ca.us/health/EMS/|title=Monterey County Health Department website|accessdate=2008-10-08] In small communities that lack a large populationor tax-base, such a service may not be able to operate unless it is staffed by community volunteers. [cite web|url=http://www.monroeems.org/|title=Monroe Volunteer EMS website|accessdate=2008-10-08] In these cases, the volunteer squad may receive some funding from municipal taxes, but is generally heavily reliant on voluntary donations to cover operating expenses. This provides a significant challenge for volunteer groups, since the training standardsfor staff must be met, and the vehicle and equipment standards adhered to, while the group does all or most of its own fundraising. Without the presence of dedicated volunteers, however, many small communities in America might be without local EMS systems and would either have no service at all or be forced to rely on service from more distant communities.
Another operating model for publicly-operated EMS is what is generally referred to in the industry as the 'third service' option. In this option, rather than being an integral part of (or in some cases, an 'add-on' to) one of the traditional 'emergency' services (fire and police), the service is organized as a separate, free-standing, municipal
department, with organization that may be similar to, but operated independently from, either the fire or police departments,. [cite web|url=http://www.cityofno.com/Portals/EMS/portal.aspx|title=New Orleans EMS website|accessdate=2008-10-08] In a variant of this model, the EMS system may be recognized as a legitimate third emergency service, but provided under a contractual agreementwith another organization, such as a private company or a hospital, instead of direct operation. This model is sometimes referred to as the 'public utility' model. [cite book |author=Jon R. Krohmer |title=Principles Of Ems Systems |publisher=American College of Emergency Physicians |location= |year=2005 |pages=149-150 |isbn=0-7637-3382-2 |oclc= |doi= |accessdate=2008-10-08] This may be a cost-saving measure, or it may be because the community feels that they lack the resident expertise to deal with medical oversight and control issues, and the legal requirements that typically surround an Emergency Medical Service.
In yet another model for publicly-operated EMS, the system may be integrated into the operations of another municipal emergency service, such as the local
fire departmentor police department. This integration may be partial or complete. In the case of partial integration, the EMS staff may share quarters, administrative services, and even command and control with the other service. [cite web|url=http://fdnyems.com/|title=FDNYEMS website|accessdate=2008-10-08] In the case of full integration, the EMS staff may be fully cross-trained to perform the entry-level function of the other emergency service, whether firefightingor policing. [cite web|url=http://www.mspaviation.org/frames.asp|title=Maryland State Police Aviation Command website|accessdate=2008-10-09] Many communities perceive this as providing 'added value' to the community, since municipal workers are fulfilling more than one function, and are less likely to be idle.
Private/for profit EMS
Ambulance services operating on a private/for profit basis have a long history in the U.S. Often, particularly in smaller communities, ambulance service was seen by the community as a lower priority than police or fire services, and certainly nothing that should require public funding. Until the professionalization of emergency medical services in the early 1970s, one of the most common providers of ambulance service in the United States was a community's local funeral home. [cite book |author=Jon R. Krohmer |title=Principles Of Ems Systems |publisher=American College of Emergency Physicians |location= |year=2005 |pages=146|isbn=0-7637-3382-2 |oclc= |doi= |accessdate=2008-10-09] Funeral home ambulance operations were sometimes supplemented by 'mom and pop' operations, which weren't affiliated with funeral homes but rather operated on much the same basis as a taxi service. Such companies continue to operate this way in some locations, providing non-emergency transport services, fee-for-service emergency service, [cite web|url=http://www.guardianambulance.org/ver_1.html|title=Guardian Ambulance Ltd. website|accessdate=2008-10-09] or contracted emergency ambulance service to municipalities, as in the public utility model. [cite web|url=http://www.emergencyambulance.com/main.html|title=Emergency Ambulance Service Ltd website|accessdate=2008-10-09] During the late 1970s and early 1980s, more than 200 private ambulance companies in the U.S. were gradually merged into large regional companies, some of which continue to operate today. [cite web|url=http://www.acadian.com/|title=Acadian Ambulance Company website|accessdate=2008-10-09] As this trend continued, the result was a few remaining private companies, a handful of regional companies, and two very large multinational companies which currently dominate the entire industry. [cite web|url=http://www.amr.net/|title=American Medical Response website|accessdate=2008-10-09] [cite web|url=http://www.ruralmetro.com/|title=Rural Metro Corporation website|accessdate=2008-10-09 ] These services continue to operate in some parts of the U.S., either on a fee-for-service basis to the patient, or by means of contracts with local municipalities. Such contracts usually result in a fee-for-service operation which is funded by the municipality on a supplementary basis, in exchange for formal guarantees of adequate performance on such issues as staffing, skill sets, resources available, and response times. [cite web|url=http://mountainenterprise1.netfirms.com/ambulance_service/AmbPerfStds_Draft5_11-10-06.pdf|title=Draft EMS Contractor Performance Standards, Kern County, California|accessdate=2008-10-09]
Model of care
The Emergency Medical Service system in the United States typically follows the Anglo-American (as opposed to the Franco-German) model of service delivery. Apart from a handful of doctors who work on
Medevacaircraft or perform training or medical quality assurance, it is extremely uncommon to see a physician deliberately responding to the scene of an emergency. [cite journal |author=Dick WF |title=Anglo-American vs. Franco-German emergency medical services system |journal=Prehosp Disaster Med |volume=18 |issue=1 |pages=29–35; discussion 35–7 |year=2003 |pmid=14694898 |doi= |url=]
Air ambulanceservices in the United States can be operated by a variety of sources. Some services are hospital-operated, [cite web|url=http://www.airlifedenver.com/|title=AirLifeDenver website|accessdate=2008-10-02] while others may be operated by Federal, Stateor local government; or through a variety of departments, including local or State police, [cite web|url=http://www.mspaviation.org/frames.asp|title=Maryland State Police Aviation Command website|accessdate=2008-10-02] the United States Park Service, [cite web|url=http://www.nps.gov/uspp/avipag.htm|title=US Parks Police website|accessdate=2008-10-02] or Fire Departments. [cite web|url=http://www.fire.lacounty.gov/EMS/EMS.asp|title=Los Angeles County Fire Department website|accessdate=2008-10-02] Such services may be operated directly by any of these EMS systems, or they may be contracted to a third-party provider, such as an aircraft charter company. In addition, it is not uncommon for U.S. militaryhelicopters to be pressed into service providing air ambulance support. The vast distances covered by the U.S. mean that while helicoptersmay be the preferred form of service delivery for 'on-scene' emergencies, fixed wingaircraft, including small jets, are often used for transfers from ruralhospitals to tertiary caresites. These aircraft are typically staffed by a mix of personnel including physicians, nurses, and paramedics, and in some cases, by all three. Publicly operated air ambulance service is supplemented by emergency and non-emergency air transport service, which may be provided by dedicated air ambulance companies, or by aircraft chartercompanies as a 'sideline' business operation.
Prior to the 1970s,
ambulanceservice was largely unregulated. While some areas ambulances were staffed by advanced first-aid-level responders, in other areas, it was common for the local undertaker, having the only transport in town in which one could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. However, after the release of the National Highway Traffic Safety Administration's study, "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in the EMS trade as the White Paper) [cite journal |author=Gaston SR |title="Accidental death and disability: the neglected disease of modern society". A progress report |journal=J Trauma |volume=11 |issue=3 |pages=195–206 |year=1971 |month=March |pmid=5545943 |doi= |url=] a concerted effort was undertaken to improve emergency medical care in the pre-hospital setting.
In the late 1960's, Dr.
R Adams Cowleywas instrumental in the creation of the country's first statewide EMS program, in Maryland. The system was called the Division of Emergency Medical Services (now known as the Maryland Institute for Emergency Medical Services and Systems). Also in 1969, Cowley was obtained a militaryhelicopter to assist in rapidly transporting patients to the Center for the Study of Trauma (now know as the R Adams Cowley Shock Trauma Center), a specialized hospital that he had started for the purpose of treating shock. This service was not only the first statewide EMS program, but also the beginning of modern emergency medical helicopter transport in the United States. [ [http://www.umm.edu/shocktrauma/history.html History ] ]
civilianhospital-based medical helicopter program in the U.S., Flight For LifeColorado, began in 1972 with a single Alouette III helicopter, based at St. Anthony Central Hospital in Denver, Colorado. [cite web|url=http://www.flightforlifecolorado.org/index.php?s=5|title= Flight for Life Colorado website|accessdate=2008-10-01]
National EMS standards for the US are determined by the
U.S. Department of Transportationand modified by each state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Committees (usually in rural areas) or by other committees, or even individual EMS providers. In addition, the [http://www.nremt.org/ National Registry of Emergency Medical Technicians] , an independent body, was created in 1970 at the recommendation of President Richard M. Nixonin an effort to provide a nationally accepted certification for providers and a nationwide consensus on protocols. Currently, National Registry certification is accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.
A significant event in the development of modern standards of care in the U.S. was a report published in 1966 by the National Academy of Sciences entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", commonly referred to as "the White Paper." In this study, it became apparent that many of the deaths occurring every day were unnecessary, and could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments.
In particular, in the US state of
California, in Seattle, Washingtonstate (see Medic One), and in Miami, projects began to include paramedics in the EMS responses in the early 1970s. Groups in Pittsburgh, Pennsylvaniaand Portland, Oregonwere also early pioneers in pre-hospital emergency medical training. Despite opposition from firefightersand doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the television series, " Emergency!" which, in part, followed the adventures of two Los Angeles County Fire Departmentparamedics as they responded to various types of medical emergency. James O. Pageserved as the series technical adviser and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.
Ambulances in the United States are usually staffed by at least two crew members. Many areas require that at least one crew of those crew members be a certified or licensed EMT, enabling this person to continue to provide medical care en route to the hospital while the other crew member drives the ambulance.
Funding and manpower models
Outside of large cities, EMS is most often provided by volunteers; owever, due to the increasing intensity of training, EMS is becoming more of a paid profession. Even agencies that were once strictly volunteer have begun supplementing their ranks with compensated members in order to keep up with booming call volumes. As of 2004, the largest "Private Enterprise" provider of contract EMS services in North America is AMR, or
American Medical Response, [cite web|url=http://www.amr.net/|title=AMR website|accessdate=2008-10-01] based in Greenwood Village, Colorado. The second-largest US EMS provider is Rural/Metro Corporation, [cite web|url=http://www.ruralmetro.com/|title=Rural/Metro website|accessdate=2008-10-01] based in Scottsdale, Arizona; Rural/Metro Corporation also provides EMS services to parts of Latin America. Like AMR, Rural/Metro provides other transportation services, such as non-emergency transport and "coach," or wheelchair, transportation.
Many colleges and universities now also have their own EMS agencies for their campuses. Collegiate EMS programs vary somewhat from university to university; however, most agencies are fully staffed by student volunteers. Agencies might operate what is called a Quick Response Service (which does not transport patients but acts as a first responder to scenes) providing initial patient assessment and care, or they might operate certified ambulance services staffed with EMTs or Paramedics. Some groups limit services to within their campus, while others extend services to the surrounding community. Services provided by college and university agencies may include ambulance services, mass-casualty incident response, aero-medical services, and search-and-rescue teams.Will H, Jones KO, [http://www.collegehealth-e.org/3/n05.htm "An Overview of Collegiate Emergency Medical Services."] "collegehealth-e," Issue 3 (June-July 2006), pp. 13-14. ( [http://www.collegehealth-e.org/3/ems.pdf PDF] )] While Fire Service in the US is rated based on ISO classes, and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. This often forces EMS to depend on emotional pleas for funds during difficult financial times.
Training and certification
The original lines that delineated an EMT from a Paramedic and a Paramedic from a doctor are becoming increasingly blurredFact|date=March 2008. Skills that were once reserved for
physiciansare now routinely performed by paramedics, and skills once reserved for paramedics, such as defibrillation, are now routinely performed by Basic Emergency Medical Technicians (EMTs)Fact|date=March 2008. However, there is wide variation among states, and even among counties within states, of what type of care providers at different levels are allowed to provide. In addition to these variations, some states and counties allow for "add-ons", such as defibrillationor IV therapy, which enable workers at a lower level to learn and use additional skills that would not normally be within the scope of practiceof their qualification level (for example, an EMT-Basic is not generally permitted to start an IV, but after successfully completing an IV add-on course, he or she would then be able to do so.)
A coarse-grained listing of qualification levels, not taking into account variations and add-ons, is the following:
Certified first responder(CFR): CFRs, many of whom are volunteers, render very basic first aid , including oxygen administration, to patients. Generally, a CFR cannot assume care for a patient while that patient is being transported.Fact|date=March 2008
Emergency Medical Technician(EMT): "EMT" is used two different ways, one more specific than the other. In general, an EMT is a person who has been certified (or licensed, in some states) to provide a stated level of care based on written protocols. However, EMTs may be divided into several groups based on their level of certification and permitted skills:
EMT Intermediate(EMT-I) (Note: not found in all states)
EMTs other than EMT-Bs are typically identified based on their level of certification. For example, an EMT-P is generally called a "paramedic" in the field, and not an "EMT". The title "EMT", when used alone, therefore generally refers to an "EMT-B".
In addition to the Paramedic level, Critical Care Paramedics specialize in the management of critical trauma and medical patients during interfacility ground and aeromedical transports. Skills performed by CCPs include ventilator management, IV pump infusion maintenance, aortic balloon pump monitoring, and specialized hemodynamic monitoring.
Reciprocity - that is, recognition of one state's EMT certification being valid in another state - between states is somewhat limited, and after 30 years of operation by the
National Registry of Emergency Medical Technicians, only about 40 states provide unlimited recognition of the NREMT certifications. [cite web|url=http://www.nremt.org/about/nremt_news.asp|title=NREMT website|accessdate=2008-10-01] In reality, there are at least 40 types of certification for EMS personnel within the United States, and many of these are recognized by no more than a single state. This creates significant challenges for the career mobility of many EMS providers, as they must often re-sit certification examinations each time they move from one state to another.
EMS providers work under the authority and indirect supervision of a
medical director, or board-certified physicianwho oversees the policies and protocols of a particular EMS system or organization. [cite web|url=http://www.co.fresno.ca.us/uploadedFiles/Departments/Public_Health/Divisions/EMS/content/Policies,_Procedures_and_Memos/content/Fresno,_Kings_and_Madera_Counties/001_-_099/021.pdf|title=Department of Community Health Policies and Procedures (EMS website)|accessdate=2008-10-02] Both the medical director and the actions he or she undertakes are often referred to as "Medical Control".
Equipment and procedures are necessarily limited in the pre-hospital environment, and EMS professionals are trained to follow a formal and carefully designed
decision tree(more commonly referred to as a "protocol") which has been approved by Medical Control. This protocol helps ensure a consistent approach to the most common types of emergencies the EMS professional may encounter. Medical Control may take place on-line, with the EMS personnel having to contact the physician for direction delegationfor all Advanced Life Support ( ALS) procedures, or off-line, with EMS personnel performing some or all of their ALS procedures on the basis of protocolsor 'standing orders'.
Ambulances in the
United Statesare defined by federal KKK-1822 Standards requirements, [cite web|url=http://www.upton.ma.us/media/EMS/ambulanc_1_R2FI5H_0Z5RDZ-i34K-pR.pdf|title=U.S. General Services Administration website|accessdate=2008-10-01] which define several categories of ambulances. In addition, most states have additional requirements according to their individual needs.
* Type I Ambulances are based on the chassis-cabs of light duty pickup-trucks,
* Type II Ambulances are based on modern passenger/cargo vans, also referred to as "Vanbulances",
* Type III Ambulances are based on chassis-cabs of light duty vans,"AD" (Additional Duty) versions of both Type I and Type III designs are also defined. They include increased
GVWR, storage and payload capacity.
Large American cities like New York and
Los Angelestend to have many distinct ambulance services, each with its own paint scheme and using all of the ambulance types mentioned above. Pedestrians and drivers in such cities must be alert for ambulances of many shapes, sizes, and colors. Most ambulances certified for emergency response in the U.S. are marked with the Star of Lifefor ready identification by the public.
Type I ambulance
A_typical_Type II ambulance
A_typical_Type III ambulance
Rapid response vehicles
Ambulances may be supplemented or supported by vehicles that lack the capacity to transport a patient. [cite web|url=http://www.upton.ma.us/media/EMS/ambulanc_1_R2FI5H_0Z5RDZ-i34K-pR.pdf|title=U.S. General Services Administration website|accessdate=2008-10-01] The most common of these vehicles is known by several names, including "
fly-car". Fly cars are often equipped with much of the equipment carried by an ambulance, but, since they are SUVs or large cars, they are often faster and nimbler. Fly-cars are staffed by one or more medical providers, and are used variously as a source of additional (or more skilled) manpower, as a supervisor's vehicle, or as a first response vehicle, enabling medical treatment to begin before the arrival of the ambulance.
In the United States, there are as many methods of dispatching EMS resources as there are approaches to EMS service provision. In some larger communities, EMS may be self-dispatching. Where EMS is operated as a division of the Police or Fire Departments, they will generally be dispatched by those organizations. Dispatching may occur through State-licensed EMS dispatch centres, operated by one service, but providing dispatch to several counties. In large centers, such as
New York City, the statutory EMS provider (in this case the NYFD) will dispatch not only their own vehicles, but also EMS resources belonging to hospitals, private companies, and even volunteers, within their own community. The national emergency number in the United States is 9-1-1. The number works for all three emergency services. In most cases, the 9-1-1 call will be answered at a central facility, usually referred to as a Public Safety Answering Point, operated in most cases, but not all, by the police. The needs of the caller are identified, and the call routed to the dispatcher for the emergency service(s) required.
While some small communities continue to use 'low-tech' approaches to dispatch, in many places in the U.S. the technology is quite advanced. Features include electronic mapping,
Global Positioning System(GPS) or its' first cousin Automatic vehicle location(AVL). The use of decision support software, [cite web|url=http://www.mresnet.com/mresscreenshots.asp|title=MRES website|accessdate=2008-10-02] such as AMPDSis also common, as are surveillance'add-ons'. As a result, many dispatchers are trained to a high level in their own right, triaging incoming calls by severity, and providing advice or medical guidance by telephone, prior to the arrival of the ambulance or rescue squad. Some are certified as EMTs or paramedics in their own states, and increasingly, are becoming certified as Emergency Medical Dispatchers ( EMDs). [cite book |author=Kuehl, Alexander |title=Prehospital systems and medical oversight |publisher=Kendall/Hunt Pub |location=Dubugue, Iowa |year=2002 |pages=192 |isbn=0-7872-7071-7 |oclc= |doi= |accessdate=]
There is no official standard in the United States, based upon either Federal or State law, with respect to response times. [cite web|url=http://publicsafety.com/article/article.jsp?id=2255&siteSection=5|title=EMS Response Time Standards (article) 1|accessdate=2008-10-02] Response time standards frequently do exist in the form of contractual obligations between communities and EMS provider organizations. As a result, there is typically considerable variation with respect to standards from one community to another. New York City, for example, mandates a 10 minute response time on emergency calls, [cite web|url=http://query.nytimes.com/gst/fullpage.html?res=9C0CE1D81F3DF936A15750C0A966958260|title=New EMS Response Times (NY Times article)|accessdate=2008-10-02] while some communities in California have moved response time standards to 12-15 minutes. [cite web|url=http://publicsafety.com/article/article.jsp?id=2255&siteSection=5|title=EMS Response Time Standards (article) 2|accessdate=2008-10-02] It is generally accepted within the field that an 'ideal' response time for emergency calls would be within eight minutes ninety percent of the time, but this objective is rarely achieved and current research results question the validity of that standard. [cite journal|author=Pons PT, Markovchick VJ|title=Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?|journal=Journal of Emergency Medicine|volume=23|number=1|year=2002|url=http://www.ingentaconnect.com/content/els/07364679/2002/00000023/00000001/art00460;jsessionid=1c7uhf68322kj.alexandra] As call volumes increase and resources and funding fail to keep pace, even large EMS systems such as Pittsburgh, Pennsylvania [cite web|url=http://www.wpxi.com/target11/13331250/detail.html|title=Pittsburgh EMS Response Time Below National Standard|accessdate=2008-10-02] or Augusta, Georgia [cite web|url=http://www.nbcaugusta.com/news/local/2462646.html|title=Aiken County to Discuss EMS Response Time (article)|accessdate=2008-10-02] struggle to meet these standards. This issue is further complicated by performance measurement methodology, with some services counting response time from the moment that the telephone call is answered until an ambulance or response resource arrives at the scene, while others measure only the time from the notification of EMS personnel of the call, which is considerably shorter. Another issue which arises in urban areas is that almost universal, is that the response time 'clock' stops when the unit arrives in front of the address. In large office or apartment buildings, actually accessing the patient may take several minutes longer, but this is not considered in response time calculation or reporting. [cite journal|author=Silverman RA, Galea S, Blaney S, Freese J, Prezant DJ, Park R, Pahk R, Caron D, Yoon S, Epstein J, Richmond NJ|title=The "Vertical Response Time": Barriers to Ambulance Response in an Urban Area|journal=Academic Emergency Medicine|volume=14|number=9|pages=772-778|url=http://www3.interscience.wiley.com/journal/119819559/abstract]
Emergency Medical Services
Emergency Medical Dispatcher
Certified first responder
Emergency medical technician
Emergency medical responder levels by state
Paramedics in the United States
The White Paper
* [http://www.nremt.org National Registry of Emergency Medical Technicians]
* [http://www.naemt.org National Association of Emergency Medical Technicians]
* [http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.2a0771e91315babbbf30811060008a0c/ National Highway Traffic Safety Agency, Office of Emergency Medical Services]
* [http://firstaid.about.com/od/emergencymedicalservices/qt/06_EMTBvsP.htm The Difference Between an EMT and a Paramedic]
Wikimedia Foundation. 2010.
Look at other dictionaries:
Emergency medical services in the United Kingdom — An ambulance of the South Western Ambulance Service responds to an emergency call … Wikipedia
Medical centers in the United States — Health care in the United States Public health care Federal Employees Health Benefits Program Indian Health Service Medicaid Medicare Military Health System / TRICARE State Children s Health Insurance Program (SCHIP) Veterans Health… … Wikipedia
Emergency medical services — A road ambulance of the South Western Ambulance Service in England … Wikipedia
Emergency medical services in South Africa — Infobox Country common name = South Africa capital = Pretoria [cite web|url=https://www.cia.gov/library/publications/the world factbook/geos/sf.html|title=All facts unless otherwise cited are from: The CIA World Fact Book|accessdate=2008 10 06]… … Wikipedia
The United States of America — The United States of America † Catholic Encyclopedia ► The United States of America BOUNDARIES AND AREA On the east the boundary is formed by the St. Croix River and an arbitrary line to the St. John, and on the north by the… … Catholic encyclopedia
Emergency medical services in Germany — Infobox Country common name = Germany capital = Berlin [cite web|url=https://www.cia.gov/library/publications/the world factbook/geos/gm.html|title=All facts unless otherwise cited, are from: The CIA World Fact Book|accessdate=2008 10 06] area… … Wikipedia
Emergency medical services in Israel — Infobox Country common name = Israel capital = JerusalemThe Jerusalem Law states that Jerusalem, complete and united, is the capital of Israel and the city serves as the seat of the government, home to the President s residence, government… … Wikipedia
Health care reform in the United States — ] Current estimates put U.S. health care spending at approximately 16% of GDP. [http://www.cms.hhs.gov/NationalHealthExpendData/25 NHE Fact Sheet.asp#TopOfPage National Health Expenditure Data: NHE Fact Sheet, ] Centers for Medicare and Medicaid… … Wikipedia
Vehicle registration plates of the United States — License plates of the 50 U.S. states and the District of Columbia phonetically spelling the Preamble to the United States Constitution, displayed in the Smithsonian Institution. In the United States, license plates are issued by an … Wikipedia
Threatening the President of the United States — Criminal law Part of … Wikipedia