Challenges of applying bus ambulances in pre-hospital EMS in Iran: a qualitative study

Ambulance buses (AmBus) may provide additional transport capacity and support the management of mass-casualty incidents (MCIs), particularly when the number of casualties exceeds the capacity of conventional ambulances. However, in Iran, limited qualitative evidence is available regarding how pre-hospital emergency medical services (EMS) personnel experience the use of AmBus in actual missions, simulation exercises, and group patient-transport operations. Understanding these experiences is important because the practical usefulness of AmBus may depend not only on transport capacity, but also on vehicle design, equipment availability, staffing, team coordination, operational protocols, and personnel training. We therefore explored the experiences of Iranian prehospital EMS personnel regarding AmBus use across different mission types. This qualitative study was conducted using a conventional content analysis approach. Purposeful sampling with maximum variation was employed to recruit pre-hospital EMS staff, nurses, and field supervisors who had experience participating in missions involving AmBus in real-world deployments, simulation drills, and group transfers. Sampling continued until data saturation was achieved. Data were collected through in-depth semi-structured interviews with 51 participants; because some participants were interviewed more than once to clarify and validate emerging interpretations, a total of 57 interviews were conducted. The interviews were audio-recorded, transcribed verbatim, and analyzed using MAXQDA/10 software. Data analysis resulted in the emergence of five main themes and ten subthemes: “ambulance bus as a capacity-enhancing tool for MCI response,” “structural and equipment-related challenges of the ambulance bus,” “complexity of scene management and team coordination,” “psychological and physical burden on staff,” and “need for training, drills, and specific protocols.” Participants viewed AmBus as both an opportunity (increased capacity, simultaneous triage and care) and a challenge (limited space, insufficient equipment, role ambiguity, high stress). From the perspective of the participating Iranian pre-hospital EMS personnel, AmBus may be a useful option for increasing transport capacity during selected mass-casualty and group patient-transport missions. However, its practical use appears constrained by limitations in vehicle design, equipment, coordination, role clarity, staff support, and specialized training.