Ambulance Service Across the U.S. Is in Critical Condition, Experts Say : Mismanagement and Inefficiency Plague Many Systems, Critics Charge

American ambulance service is in such a state of emergency that some cities should set red lights flashing and sirens wailing, experts say.

Emergency medical service “for certainly more than half the United States . . . ranges from deep trouble to critical but stable,” said Jack Stout, a Miami consultant who has designed ambulance systems in six cities.

“EMS is some of the nation’s largest cities is in critical condition. Absolutely critical. They’re out of control or broken down,” said James Page, chief of the Monterey Park, Calif., fire department, which handles ambulance runs, and publisher of the Journal of Emergency Medical Services.

Emergency care has improved dramatically from the 1960s when broken bodies were simply scooped off the pavement and whisked to the nearest hospital, without thought to on-site care. Given today’s capabilities, however, deaths from injury and heart attack are considered unacceptably high.

Quality Falls Off

Quality and control have fallen off with a drop in federal money, lack of federal oversight and haphazard training, according to some critics. Too many systems are plagued by mismanagement, inefficiency, poor design and simple mistakes.

One tip-off to a troubled system is access. Less than half of the U.S. population can get an ambulance by dialing 911. Others must know the exact department or agency to call. Britain has used a 999 number since 1930.

A properly organized and equipped national EMS system could prevent 30,000 heart attack deaths and 25,000 deaths by injury each year, according to estimates by the National Academy of Sciences.

“We’re killing more of our own citizens in a year than were killed in all of Vietnam,” said James Hitlin, a former paramedic in Florida and a lobbyist for a bill to promote a national EMS program. “We’re forfeiting lives because of disorganization.”

Spot Check of Service

A spot check of ambulance service in major cities by the Associated Press found:

- In Washington, D.C., a man who suffered a seizure on Jan. 17 waited 38 minutes for a lost ambulance. His family finally drove him to a hospital, where he died. Callers to 911 in the capital city sometimes get a recorded message. Ambulances routinely take 30 minutes to arrive.

- In New York City, where 100 ambulances are dispatched every hour, two paramedics were disciplined for waiting for their sandwiches in a deli despite a call to help a man dying from a heart attack less than two blocks away on Feb. 17. Last August, a 70-year-old woman died of heart failure after a two-hour wait for an ambulance and three calls to EMS by friends and relatives. Officials blamed a dispatching mix-up and a shortage of units for the delay.

On the other hand:

- In Tulsa, Okla., a computer knows in an instant the ambulance nearest an emergency; instead of being parked at a station house, each vehicle moves around under guidance of the computer, which calculates when and where accidents and heart attacks are apt to happen. Radar tracks the ambulance, shown as a magenta blip on a 30-inch electronic screen, so it can’t get lost. Ambulances must respond in 8 minutes 90% of the time or the private company that runs the service is fined.

Praise for Seattle

- Seattle draws praise for its life-saving rate. Fire department paramedics revive half of the 300 people who suffer heart attacks each year, giving them a chance to make it to a hospital. About 80 of those 150 recover completely. Citizens also get involved. Cardiopulmonary resuscitation is mandatory in King County schools and part of health studies in Seattle schools.

The type of service varies from city to city. Some ambulances are run by fire departments, others as separate municipal services. Some cities hire private companies, others rely on hospitals. Volunteers handle emergencies in 30% of the cases nationwide, but only one of the 150 largest cities has a volunteer service.

As recently as the 1960s, most ambulances were operated by funeral homes because hearses were the only rigs big enough to carry patients on cots. Care was crude, and rides were rough-and-tumble.

“Those were the days of ‘You call. We haul. That’s all,”’ said John Chew, EMS program director for the U.S. Department of Transportation.

Government Stepped In

The federal government stepped in 22 years ago, telling states to upgrade emergency services to provide some form of rudimentary medical care. The Highway Safety Act of 1966 was used to pressure reluctant states with the threat of forfeited highway money.

In 1973, the Emergency Medical Act went further, providing $30 million over seven years to establish a nationwide EMS network. But in 1981, oversight shifted and money got tighter under the Reagan policy of putting most federal funds into block grants.

That left the states to decide how to divvy up all Preventive Health and Health Services money among such programs as ambulances, rat control and fluoridation.

EMS allocations dropped 34% from 1981 to 1983, according to the General Accounting Office, which was asked to review the system by Democratic Sens. Alan Cranston of California and Edward M. Kennedy of Massachusetts.

State spending has made up some of the difference since but has not hit previous levels, the GAO said.

Cranston Sponsors Bill

Cranston has sponsored a bill to provide $75 million for EMS and trauma centers over three years. A similar bill is pending in the House.

Ambulance care has evolved on two levels. Basic life support offers cardiopulmonary resuscitation, bandages and oxygen provided by emergency medical technicians. Advanced life support features highly skilled paramedics who can inject medicine, restart hearts with electric jolts and clear airways with tubes.

The country has 400,000 EMTs and 35,171 paramedics. Federal guidelines suggest 110 hours of training for EMTs, as many as 1,000 hours for paramedics. Only 30 states require certification through a written and practical test for paramedics given by the National Registry of Emergency Medical Technicians.

In some states, paramedics get less schooling than hair stylists. In Ohio, for example, hair stylists train 1,800 hours for a license; a paramedic needs only 1,000 hours.

“There are very few jobs where somebody’s life is in hands that take less training,” said William Burns of the national registry.

To get better performance, some cities have turned to private companies. Pinellas County, Fla., which includes Tampa and St. Petersburg, pays Hospital Corp. of America $727,000 a month for ambulance service.

No Incentive in Public Sector

“There’s no incentive to be efficient in the public sector,” said Robert Forbuss, president of the American Ambulance Assn. and head of a private ambulance company in Las Vegas. “They’re at the mercy of unions and Civil Service. You can’t fire the fire department if it does a bad job.”

About 65% of EMS providers are volunteers, but paid professionals cover the largest cities and care for 70% of the population, according to the federal government.

Increasingly, towns are abandoning volunteer systems, due to demand for more sophisticated care and to fewer people who can balance the demands of regular jobs with the time needed for emergency work.

“The volunteer system is crumbling. There’s no place for volunteers in a professional service,” said Patrick Kennedy, president of a private ambulance company that serves Reading, Pa.

“We’re not making cookies or putting out fires out here. You can rebuild a building. You can’t rebuild a life.”