The French pre-hospital system operates through 13 regional subdivisions, each with its own EMS organization called “SAMU,” “SMUR,” and fire departments. The system is centralized, with national telephone numbers for medical emergencies (15 for SAMU, 18 for the fire department, and 112 for both) (37). Response times aim for BLS ambulances to reach metropolitan areas in 10 min, medical teams in 10 min−20 min, and rural locations in 30 min at most. French EMS providers consist of firefighters/EMT, nurses, and emergency physicians.

French medical intensive care ambulances are equipped with advanced life support technology, resembling resuscitation rooms, and offer pre-hospital treatment and transportation for patients with specific needs, such as newborns and pediatric patients (37).

The French system follows a hybrid approach, combining elements of both “scoop and run” and “stay and play” strategies depending on the patient's condition, context, and location (38). The organization includes BLS ambulances (mainly firefighters), ALS medicalized intensive care ambulances and in some places nurse vehicles (39). In the intricate ballet of extra-hospital medical interventions, each movement is gracefully orchestrated under the vigilant and discerning eye of the regulating physician, ensuring a harmonious symphony of care (40).

Pre-hospital systems in English-speaking countries exhibit decentralization and fragmentation, with various EMS providers operating at the local level (41). Response times vary depending on the area and type of EMS service, aiming for an arrival time of 8 min to 12 min in urban areas. Personnel and training levels differ among English-speaking countries, with EMS teams consisting of paramedics, emergency medical technicians, and physicians, each requiring different levels of training. The equipment and services provided by EMS providers may vary based on location and business models.

The EMS hierarchy comprises basic life support (BLS) and advanced life support (ALS) stages, with state-specific utilization rates. BLS involves simple measures that can be performed by emergency medical personnel during transportation, while ALS includes invasive procedures such as endotracheal intubation and intravenous catheterization for managing complicated patients and delivering medications and fluids (41). However, EMTs could actually perform defibrillation, intramuscular injection of epinephrine and naloxone, and placement of supraglottic airways. Availability of specialist ALS services may vary, especially in rural areas, leading to potential delays and coordination challenges (42).

The Magen David Adom (MDA) is the sole EMS provider in the national-level Israeli pre-hospital system. With a single national phone number (101) for medical emergencies, the system is centralized. MDA intends to reach the scene of an emergency in urban regions within 8 min to 12 min and in rural areas within 20 min. Emergency medical technicians and paramedics make up the MDA EMS team. Between 250 h and a 2-year training program and a national certification test are requirements for all EMS providers. Paramedics have a 1-year course or a 3-year Bachelor's degree. Modern life support technology and transport trucks are available at MDA EMS. For patients with unique needs, such as newborn and pediatric patients, the system also offers pre-hospital care and transportation.

Technology developments have also had an influence on the “scoop and run” vs. “stay and play” argument. Indeed, the “scoop and run” strategy was helped by French inventions and “stay and play” was helped by English-speaking ones.

Significant advancements in favor of “advanced field care” emerged during different historical periods. In World War I, the “petites Curies” mobile radiology unit was introduced, while the US Army Medical Service developed accessible transportation strategies during World War II (13, 43). Portable respirators led to the establishment of the corps of anesthesiologists-reanimators, and in 1956, the first inter-hospital transfer of patients on mechanical ventilation took place during the polio outbreak (44). Lyophilized plasma transfusion was initiated in 1994 through regional and national agreements (45, 46). The MORPHEE ICU unit was introduced in 2006, and in the 2010s, pre-hospital teams started utilizing Point of Care Ultrasound (POCUS) for assessments and diagnoses, redirecting patients to appropriate services (47, 48). New technologies like extracorporeal CPR and the Mobile Brain Stroke Unit with an onboard CT scanner were developed, while electrocardiogram became crucial for diagnosing acute coronary syndrome and Point-of-Care Troponin (POCT) or ionogram system useful in several pre-hospital situations (49–52).

Conversely, a number of developments have made the “scoop and run” more popular. Félix Hippolyte Larrey (1808–1895) continued his father's legacy by using mobile medical units to treat injured civilians during the French Revolution in 1830. Lucien Baudens (1804–1857) introduced the “Baudens' box” for stabilizing fractures during transportation (53). Charles Chrétien Henri Marc (1771–1845) published recommendations for immediate treatment of drowned and asphyxiated individuals in 1835. In the Russo-Japanese War of 1904, injured soldiers were transported using geophysical adaptation and sled evacuation, with Red Cross workers skiing over the snow (54). The medicalization of transportation and prompt resuscitation in the 1950s led to a decrease in the number of patients sent to advanced medical facilities. Lt. Alexis Santini (1914–1997) conducted the first helicopter transportation during the Indochina war (16). Olivier board (1950) provided stabilization during transportation, and Sauveur Piguillem (1930–2018) developed the Piguillem stretcher for airlifting in 1954. The VSAB (Emergency Vehicles for Asphyxiated and Injured) used to be called VSAV and underwent a name change in 2012. It is also worth highlighting the many changes that have contributed to the upscaling of rescue teams such as ECGs teletransmitted to medical regulation, new gestures (administration by aerosol, oral, intranasal or spraying of medicinal products, carrying out of electrocardiograms, etc.) authorized by the law of November 25, 2021, known as the Matras law.

Advancements in technology by 2030, including unmanned helicopters, pilotless flying ambulances, defibrillator-equipped support drones, and connected patient devices, will shape the concept of “EMS without eyes and without hands” (55–57). While these innovations offer promising possibilities, challenges like false positives and resource overuse must be addressed (58). Centralization and resource fusion will be crucial solutions. Telemedicine and mobile health technology enable remote patient monitoring and consultation, enhancing on-site treatment quality. Rapid point-of-care testing aids emergency physicians in making informed decisions. With these advancements, emergency physicians can effectively implement a kind of “stay and play” strategy, providing excellent on-site treatment for several medical situations.

In the “scoop and run” vs. “stay and play” argument, cost-effectiveness of various strategies is another aspect to take into account. It can be costly to convey patients to the finest hospital, especially when many cars or air transportation are required. A rescue helicopter, for example, costs 1.7 million euros a year in France, according to the French government (IGAS) (59). Further raising costs is the possibility that patients who are taken to the top hospital would need longer hospital stays or more intense care. On the other hand, providing on-site treatment may be more cost-effective in some cases, particularly for patients who do not require immediate transport to the hospital. For example, while costs of either prehospital advanced life support (ALS) and/or critical care per patient with out-of-hospital cardiac arrest (OHCA) are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive with after effects (60). However, there is actually no cost-effectiveness study to compare “stay and play” and “scoop and run” on the financial side, but several concerning effectiveness according to indications for each model.

Both the French “field medicalization” and English-speaking “Scoop and Run” approaches have their merits and drawbacks. The French approach has been criticized for potential transfer delays in time-sensitive situations like severe trauma with uncontrolled bleeding. On the other hand, the English-speaking approach has faced criticism for inadequate on-site medical treatment and potential preventable death during transportation. Choosing between the two approaches depends on individual patient needs, prehospital and hospital resources and each specific emergency situation. The French approach could be preferable when advanced medical treatment is necessary, while the English-speaking approach excels in situations where swift transportation is crucial, especially in metropolitan areas with short travel times if all hospital resources are immediately available. The ongoing debate surrounding the “stay and play” vs. “scoop and run” EMS techniques continues, with differing opinions on which strategy is superior. The French approach prioritizes thorough on-site medical care over prompt patient transfer, based on the belief that immediate attention can improve outcomes, reduce after effects and sometimes the need for hospitalization. For instance, in the context of cardiac resuscitation, “stay and treat” must be used in order to maximize the likelihood of recovery and minimize the phenomenon of prolonged ischemia (61, 62). In contrast, the English-speaking “scoop and run” strategy places a higher priority on swift hospital transfer since it is thought that fast medical assistance at a hospital is the key to lifesaving (35, 36). With many American EMS systems switching to this method of first on-scene medical care of patients in cardiac arrest, international cardiac arrest literature has demonstrated a benefit from remaining and treating on site. Indeed, among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge (63).

However, we have to add a caveat to that, as a study examining secondary carrying and transportation (to the adapted hospital/trauma center) found a correlation between increased mortality and sending badly injured patients to facilities that cannot provide definitive care (36). Moreover, despite the fact that the terms “over- and under-sorting of trauma patients” are frequently used in literature to allude to it, a randomized clinical trial compared ALS to BLS for penetrating trauma with no survival rate gain (64, 65). When it comes to specific, targeted scenarios like advanced airway care and cardiac arrest, ALS shines (63). The American approach to trauma includes quick off-scene transfer, basic airway treatment, and bleeding control (61). Medical expertise, technicality, patient care, and promptness all play a role in the nature of medical crises. While treating trauma (64, 66) or more difficult situations, time is invested in the patient's best interests by being decreased as far as is practicable by taking the time to stabilize the patient.

The practices of prehospital care in France and English-speaking countries, though nuanced in their system characteristics and outcomes, are not rigidly bifurcated. This landscape of emergency medical services shows a spectrum of approaches rather than a clear-cut division, underscoring a shared commitment to lifesaving care across different linguistic and geographic landscapes (67). This sweeping generalization fails to capture the rich tapestry of variation that characterizes the practices among English-speaking nations. It's a landscape where diversity in approach is not just common, but the norm, rendering any broad-brush characterization woefully inadequate in grasping the nuances of their medical methodologies (68). For instance, the acute trauma care systems in the US and Canada differ (69): Canada's more unified system ensures that about 80% of its populace is within an hour of a level I or II center, while the U.S., with its state-specific verification of trauma centers, presents a tapestry of variability across the country. In both Canada and the United States, efficient prehospital care is coupled with the recognition of post-discharge care as a financial challenge; while population-dense areas benefit from rapid access to well-developed trauma centers, those in remote regions face access hurdles, and with trauma centers ranging from level I (highest capability) to level IV, both systems, despite having room for improvement, effectively provide quality care to the vast majority of their injured patients.

In the “scoop and run” vs. “stay and play” argument, prehospital staff (paramedic or emergency physicians) training is a crucial consideration. Skilled and experienced caregivers will be able to initiate appropriate lifesaving interventions without losing any time.

Many countries are choosing to train their prehospital teams better and better, both for paramedics and for medical teams.

Since its founding 40 years ago (70), the French centers for emergency healthcare education (CESU) have helped to train more than 200,000 healthcare professionals each year. Since 2017 (71, 72), in France, Emergency Medicine has become a medical specialty with emergency medicine schools in the faculties of medicine in each university in France: 4-year training which will increase to 5 years to harmonize with Europe (73).

Moreover, in France, a new job concerning the EMS has appeared “Infirmier en Pratiques Avancées.” Initially, this job has been designed in order to delegate the follow-up of chronic diseases, then the mention “emergencies” on their diploma allows them to specialize in regulation, pre-hospital and in-hospital emergency medicine. Unfortunately, in terms of duration, their training (2 years into the emergency domain in addition to their initial 3 years nurse course) and lower than the English-speaking paramedics (6 months to 3 years according to the State).

In the front line of the emergency medical systems, first responders and non-medical individuals with medical expertise and flexibility are crucial and there are no “golden skills” (74).

The synthesis of information reveals the existence of diverse models within the Anglo-American (the US, Canada, and Australia…) paramedic system, where metaphorical models grounded in philosophical underpinnings delineate two novel subsystems: the professionally autonomous and the directive paramedic systems, with the latter further divided into rescue and hospital-managed submodels (75). In spite of this relative homogenous subdivision into the English-speaking world, inside the same system, the training could be different leading to various skills (76).

Physician shortages play a significant role in shaping the “scoop and run” vs. “stay and play” debate. Different countries have pioneered approaches to address this issue, with Israel influencing the English-speaking model and France contributing innovations even to the “scoop and run” approach.

Emergency physicians specialize in acute care and patient stabilization, and the choice of strategy depends on factors such as the patient population demographics and the distance between the incident location and referral hospital. Utilizing helicopters for transportation to specialized reference hospitals, like trauma centers or cardiac catheterization facilities, can be efficient in certain situations. This type of transport triage has been in existence for trauma patients since at least the mid-1980s and for myocardial infarction and stroke patients for at least two decades (77).

However, resource scarcity must be considered. The effectiveness of the “stay and play” approach varies between rural and urban areas. In rural regions, helicopter transport between smaller hospitals and major medical centers is feasible, providing access to appropriate treatments. In contrast, rural areas may lack adequate technical infrastructure in some hospitals, leading to secondary transfers that can increase morbidity and mortality. These challenges emphasize the need for diverse approaches and innovative thinking in pre-hospital emergency medicine.

In 1927, Dr. Côt introduced medical prehospital care doctrine to the Parisian military Firefighters brigade, bringing battlefield principles to civilian emergency care (14). The doctrine emphasized: (a) Bringing the hospital to the victim, (b) Ensuring rigorous conditioning before transporting asphyxiated patients, (c) Implementing proven hospital-based therapeutic processes, (d) Recognizing the importance of “prompt help” before a doctor's arrival, (e) Restoring major physiological functions before departure, (f) Providing symptomatic treatment, and (g) Using appropriate vehicles for the mission.

In 2023, these principles remain completely relevant. In the 80s/90s, to save time, the firefighter VSAB would often depart with the victims and meet the SMUR team along the way. Currently in France, due to medical recruitment challenges, there is an evolving approach that includes the deployment of “Nurse precursor emergency teams” with graduated departures, inter-hospital nursing transfers in constant communication with a regulating doctor, and the development of paramedical regulation with specialized nurses or “Infirmier en Pratiques Avancées” (IPA) to provide varying levels of response.

However, the deployment of pre-hospital medical teams has the advantage of guaranteeing quality care from the first minutes, including far from the hospital or when the emergency department is already overloaded. Moreover, It seems important to maintain the attractiveness of emergency medicine careers among young students by preserving the medical aspect of pre-hospital treatment (78, 79).

The optimal level of prehospital care is also debated internationally for disaster medicine. In 1978, the red plan—a forerunner of NOVI (Nombreuses Victimes) national plan—was unveiled, and deployed during the 1995 attacks and hundreds of situations in France. At the same time, the Advanced Medical Post (AMP) was described as a place of categorization and care to assure early life saving interventions and prioritize the most urgent evacuations (80). Unfortunately, the Parisian attacks in 2015 have led to deploy “the Alpha Red plan” (anticipated since the 2000s to prepare a damage control response for large multi-site terrorist attacks), in order to combine rapid evacuation and prehospital lifesaving interventions (81). Speed and pre-hospital death avoidance are the cornerstones of the French alpha red plan. Contrast that with the “scoop and run,” which has drawbacks in emergency care (82). The goal of priority surgical hemostasis, which can only be achieved by sophisticated field care and efficient dispatching, must not be confused with a means, such as speedy transport. Therefore, a medical system should be adaptable depending on each unique, local circumstance (74). Recently, France has witnessed a subtle yet significant shift in its health policy landscape, marked by the introduction of new legislative measures like the decree on ORSAN, unveiled in early January 2024. This pivotal document ushers in an era of regionalized crisis management, moving away from the traditional reliance on zonal recourse, signaling a nuanced evolution in the country's approach to healthcare administration (83).

Worldwide, systems have changed, frequently in reaction to other developments in their local communities and healthcare systems. For instance, the US's trauma and emergency medical services systems have adjusted to the country's high rate of non-accidental penetrating trauma.