Last November, a few weeks after the Fire Department began replacing paramedics with lesser-trained EMT firemen in ambulance squads, a woman was brought into Temple University Hospital with a rapid heartbeat.

The firemen sat her in the waiting room and left for their next call. Unbeknownst to the firemen, who were not trained to handle such situations, the woman was in the early stages of a heart attack. Soon, she would go into cardiac arrest and die.

"The firemen were doing the best they could do," says Maryann Casino, a veteran emergency room nurse, "but they shouldn't have been in that situation in the first place."

Tragedies like this make it painfully clear that things are getting worse for Philadelphia's beleaguered EMS system. According to year-end statistics released last week by the firefighter's union, emergency medical calls continued to skyrocket in 2005, reaching 252,358 — an all-time high and nearly 15,000 calls more than the year before.

Increased poverty, an aging population and the lack of affordable health care have all resulted in an ever-growing population that relies on emergency room attendants as their primary doctors. While many cities have taken measures to combat the strain these residents place upon the EMS system, Philadelphia has neither dedicated adequate resources nor figured out how to utilize existing ones better.

Recent estimates by the International Association of Fire Fighters (IAFF) hold that Philadelphia needs 30 additional ambulances to safely service its citizens. But even in the face of rising calls, the department has — during the last three months — downgraded four ambulances from advanced life-care service (ALS) to basic life-care service (BLS).

"These downgrades," says one paramedic, "are akin to an overwhelmed hospital ordering their maintenance guys to do basic care for patients."

Paramedics have long been warning that mismanagement and a lack of resources could push the city's EMS system perilously close to the point of collapse, resulting in longer and longer response times [Cover, "Emergency Breakdown," Mike Newall, May 12, 2005]. The latest statistics validate those grim predictions.

IAFF experts contend a yearly workload of more than 4,000 runs for a single ambulance squad will lead to paramedic "burnout," a dangerous cocktail of physical and mental fatigue affecting both the individual health of the paramedic and the treatment they provide to patients. Only nine of Philadelphia's 41 paramedic squads did fewer than 4,000 runs last year. More than half did between 6,000 and 9,000. And Medic Squad 22 of North Philadelphia, the busiest ambulance in the nation for two years running, responded to 9,540 calls.

"We're overwhelmed," says paramedic Dave Kearney, who is also a fire union representative, "and the city is gambling with taxpayers' lives."

Sometimes, the results are tragic. Last year, two men in their early 20s — Ricky Badway in Roxborough and Danny Rumph in Mount Airy — suffered sudden cardiac arrest and died while waiting more than 23 minutes for ambulances to arrive.

"Sadly, this type of thing happens every week," says Kearney, "but it usually happens to some elderly woman in North Philadelphia who has no one advocating for her."

According to Fire Department officials, Philadelphia's ambulances respond to emergencies within the national eight-minute standard 95 percent of the time. But Kearney says those numbers are skewed due to the way the department tracks response times.

Compared to similarly sized cities, Philadelphia deploys a relatively meager number of ambulances; after midnight, when the last of the department's part-time squads are put out of service for the night, there are only 28 squads covering all of Philadelphia. The city often experiences periods of "no squads available," sometimes on a daily basis. In many cases, precious minutes will pass before the eventual arriving ambulance is actually dispatched to the emergency call. The city does not include that lapsed time when calculating their official response times. In the case of Badway, eight minutes passed before the arriving ambulance was even dispatched.

"Our goal should be getting a paramedic on the scene of a cardiac arrest within six minutes," says Kearney. "Right now, our goal is to not run out of ambulances. The city doesn't allocate enough resources to even understand the scope of the problem, let alone deal it."

Cities with the proper amount of resources dedicated to EMS save 40 to 45 percent of these individuals; Philadelphia saves only 4 percent.

At a press conference called last week to announce the year-end stats, Fire Commissioner Lloyd Ayers skirted the EMS crisis in his prepared remarks, only addressing the issue when asked by reporters afterward. The commissioner defended the downgrades, saying that the BLS ambulances will free paramedics from having to responding to the deluge of the non-life-threatening calls that routinely tie up ambulances.

"We did an analysis of our information," said Ayers, "and found that 80 percent of the calls in the areas we downgraded were basic life support calls that could be handled by EMTs. This will free up our paramedics, our most valuable resources, to respond to more serious calls." Ayers also stated that he has requested eight additional ambulances from the city, which have yet to be granted because of budgetary reasons.

"Do I want more ambulances?" he asked. "Of course I do, but at the moment we will have to continue to do our best with what is available."

Paramedics scoff at the notion that downgrading service will ease the strain, arguing that BLS ambulances would be beneficial only if they came as additions to the existing number of ambulances. Already, say paramedics, ALS squads are being called to respond to some of the same calls as BLS ambulances since the EMTs can offer only the most basic treatment. (Frightened of possible lawsuits, the department employs only a cursory call-screening process.)

The neighborhoods targeted for downgrades have also raised eyebrows. Kensington, Point Breeze, South Philadelphia, West Philadelphia and Nicetown are predominantly black or Hispanic. Point Breeze accounts for one of the largest percentages of shooting and stabbing victims in the city, says Kearney, and Kensington is a hotbed of heroin overdoses.

Emergency room nurses are also angry. Casino, the veteran nurse, went so far as to post a sign in the emergency room waiting area: "Wake up people. We need to have our voices heard. This could be a life and death situation and it might be yours," it reads.

"We consider ourselves an extension of the paramedics and firemen," she explains. "The quality of care a patient receives in the field greatly affects the outcome in the emergency room."