Background: On February 6, a magnitude 7.8 earthquake struck southern Turkey near the Syrian border. This was followed almost nine hours later by a magnitude 7.5 earthquake situated approximately 59 miles (95 kilometers) to the southwest. The earthquake had enormous effects on the cities of Aleppo, Latakia, Hama, and Idlib, causing significant destruction and the collapse of numerous structures as well as the devastation of water supplies. United Nations estimates that about 6 million people in government-controlled areas are affected. 200,000 people in the area around Aleppo alone have been made homeless. Overall, 170 sub-districts in 43 districts in ten governorates have been impacted by the earthquake. After more than 7,000 deaths and 10,400 injuries as a result of the earthquakes' effect, humanitarian operations in Syria have become much more challenging in the context of the region's ongoing civil conflict. The Syrian Arab Red Crescent (SARC) has a long history and high capacity in providing various health services. Before the earthquake, SARC was and remains the primary provider of humanitarian assistance and offers ongoing services across most of the country in the areas of ambulance services, disaster management, water and sanitation, health and medical services, including mental health, primary and secondary services, livelihoods, and early recovery, while also incorporating an inclusive approach to community services including psychological and protection support. In 2021, SARC signed a Memorandum of Understanding with the Ministry of Health (MoH) granting it a unique position to become the lead emergency medical service (EMS) provider across all of Syria. Methods: A case study of the SARC EMS response during the February 2023 earthquake was developed utilizing following data resources • Document review: SARC operation reports, situation reports on International federation of Red Cross & Red Crescent IFRC GO platform, lesson learned workshop report, SARC operation review workshop report • Key informant interview: SARC EMS director and EMS response team leaders Description: SARC EMS dispatch in Latakia, Aleppo, and Hama received the first calls at 4.20 a.m. on the 6th of February. EMS dispatch sent ambulances and activated forward assessment commanders, and within 10 minutes, a total of 22 ambulance cars were deployed to provide prehospital medical service and general assessment in the three governorates of Hama, Aleppo, and Latakia. During the first 24 hours, the assessment and services provided were challenged by the amount of destruction and the rabble. Some extractions were delayed due to a lack of appropriate search and rescue equipment. EMS centers in the affected governorate have been activating emergency status to provide 24/7 prehospital services to the affected population. Ambulance surge support was mobilized from Tartous to Latakia (5 ambulances) and from Homs to Hama. During the first week, SARC EMS was able to respond to 406 disaster-related requests in the three governorates: 111 critically ill patients were transferred to medical facilities, 41 patients were treated on site, and that was in addition to the non-disaster-related requests. By the end of the first month, EMS had provided prehospital service to 1034 beneficiaries, 1013 injured patients, 254 dead bodies transferred, and 45 patients treated without transfer. The earthquake-affected areas have shown a significant increase, doubling in Lattakia, 43% in Aleppo, and 15% in Hama, in the demand for EMS services up to 4 months after the earthquake. Until 15th of August SARC EMS has provided prehospital services to 5,029 cases in the affected areas, 2,387 injuries transferred and 2,388 cases treated at the place without transfer. SARC EMS service has conducted 36 community-based first aid training sessions for people in the affected areas, trained more than 780 lay people. Also, SARC has fostered the capacity of SARC EMS volunt

Keywords: Syria Earthquake EMS response, Syria Arab Red Crescent, EMS disaster response