What's the difference between private ambulances and fire dept. ambulance crews (aside from who handles their payroll)?
December 6, 2010 1:16 PM   Subscribe

What's the difference between ambulances? When I dial 911 for a medical emergency, is it always Fire Dept. paramedic crew that responds? What do the other ambulances do?

I know the difference between EMT and paramedic and all that, but I'm really curious as to where the lines are drawn between private companies and gov't-run emergency services. I'm particularly curious about Seattle's situation, but general knowledge would be appreciated.

If a private ambulance crew rolls by an accident, do they stop? Or do private crews only respond to specific calls/customers?
posted by scaryblackdeath to Law & Government (15 answers total) 5 users marked this as a favorite
This probably varies a lot by municipality. I think private ambulance crews do a lot of patient transporting ie moving really sick people from nursing homes / hospices to hospitals.
posted by ghharr at 1:19 PM on December 6, 2010

In Shoreline, just north of Seattle, the fire department responds to all medical 911 calls.
posted by The corpse in the library at 1:34 PM on December 6, 2010

Sometimes the local government will contract with a private company to provide EMS. There could also be mutual aid agreements where private ambulances will be called in during large event. I believe Indianapolis is in the process of switching 911 ambulance service from the county hospital (Wishard) to the fire department so things do change.

EMS workers have a somewhat nebulous duty to act - if an EMT is eating at a restaurant on the clock and a fellow diner has a medical emergency the EMT could, in some states, some circumstances, some of the time, be legally obligated to render aid. There is a lawsuit in NY similar to this right now. This might effect the private ambulance crew in your example, but probably not if they were already transporting a paitent.
posted by ChrisHartley at 1:40 PM on December 6, 2010

Seattle has an odd system in which government paramedics respond to emergencies first, but often call in a private service (AMR) to take over if the situation is not too serious. This is a very unusual arrangement I believe.

In many areas ambulances are run by county health departments, not fire departments (which makes sense to me!).
posted by miyabo at 1:42 PM on December 6, 2010

In my area, the firefighters are trained as first responders, but are not EMTs. They tend to be closer than the actual ambulance people, since there are firehouses more uniformly distributed throughout the city. Thus, if you call for an ambulance, the fire department will show up first and hopefully be able to stabilize you enough to keep you from dying immediately, followed shortly thereafter by the ambulance service, who can do more intensive lifesaving operations while transporting you to the hospital.

The private ambulances here are only for non-emergency transport. Like if a person on a ventilator needs to be taken from the hospital to a nursing home or whatever. The semi-government ambulances also do that, but they're more expensive.

I also used to live in a city where the firefighters were also EMTs and thus had ambulances and acted as the sole ambulance service. Before that, I lived in a city with private ambulance service, where firefighters would only respond to fires or other "rescue" type situations.
posted by wierdo at 1:52 PM on December 6, 2010

In my city, private ambulances contract out with 911- you call and they get dispatched based on who's closest.
posted by aint broke at 1:59 PM on December 6, 2010

The Seattle Fire Department has Aid vans and Medic vans, and they respond to medical calls. An Aid van is for less-threatening situations. EMTs from private organizations can be called for transport after the situation is more or less settled.

You will be shocked to know how little EMTs are paid, by the way. Starting around $10 an hour.
posted by Cool Papa Bell at 2:16 PM on December 6, 2010

Where I live there are a few fire department ambulances, a bunch of volunteer ambulance corps and two commercial ambulance services. On top of that most fire departments have EMTs and other trained staff who act as first responders. The rescue trucks most fire departments have are not intended to transport patients (and often too large to enter the emergency department's facilities anyway).

When you call 911 with a medical emergency, the dispatchers will send whatever ambulance is first on the list for where you live. For me, that means the local volunteer ambulance corps. If they don't have a crew available or all their ambulances are out, the call will go to a neighboring ambulance corps or one of the commercial ambulances. If the call is severe enough and the fire department has the appropriate first responders, they will be also be sent.

All of the emergency services can talk directly to the 911 center. Fire and EMS services, whether volunteer, paid or commercial, can talk directly to each other (police are on a separate digital system). This is part of what is referred to as the Mutual Aid Plan. Being part of the plan allows agencies to request help from other agencies when needed. So if an ambulance on its way home from the hospital were to run across an accident, they would stop and begin treatment but also radio 911 that they were doing so. 911 would in turn let the responsible agency know that an incident was being worked in their district. It wouldn't matter what type of ambulance it was.

There is a separation between emergency ambulance services and medical transport services. The commercial ambulance services both have divisions that handle non-emergency transport. There are also a couple of independent companies that specialize in this. Fire department and volunteer ambulances vary on whether they will take non-emergency calls. For the few that do, you often have to arrange transport ahead of time. The rest will send you to a commercial service.
posted by tommasz at 2:31 PM on December 6, 2010

Some while back, I was told that (in that area, at least), fire stations were more prevalent, so some fire department was most likely to be the first unit on the scene. I'd assume that the ambulance would only come if necessary, for taking someone somewhere else, or for more complex medical equipment, but that's all guessing.
posted by filthy light thief at 2:37 PM on December 6, 2010

You have three different questions, first, the question about who responds when you call 911:

This varies by municipality and is basically an issue of who the municipality contracts with to provide emergency services. Typically, EMS services fall into three categories: (1) "fire based" i.e. the fire department also does EMS service; (2) "hospital based" where the ambulances live at the hospital or are administratively controlled by a hospital; (3) totally private services, the biggest of which is American Medical Response (AMR).

The most common system in the US is fire-based EMS. Ambulances / medic units live at the firehouse, and (depending on staffing arrangements) the same people might jump on either a fire engine or an ambulance-type unit depending on the call.

I've also worked in hospital-based EMS systems, and personally I rather like them (as a non-firefighter EMS provider) although they're not practical for large swaths of the country that don't have local hospitals, or a high enough call volume to justify dedicated non-firefighter EMS personnel. But some fire-based systems, particularly volunteer systems, supplement themselves with hospital-based EMS of some sort. (Typically that I've seen: hospital-based paramedics in addition to volunteer EMTs and firefighters.)

And then there are private services who get hired by municipalities, typically (at least in my experience) because they're seen as a lower-cost alternative to running a city-owned department. The pay is supposedly lower than being a municipal employee, although I've known a fair number of people who worked as municipal employees and then moonlighted with private ambulance services on their days off.

What do the other ambulances do?

The other ambulances you see driving around are probably inter-hospital transports, mostly. There are a lot of ambulance services that don't respond to calls on the street, but do transports exclusively. This is the bulk of AMR's business, I think, and there are a lot of regional companies (seemingly often called "Physician's Ambulance Service", "Doctor's Ambulance Service" etc.) that do the same thing. Some of them are getting into the 'street' side of things as well, but if you see one driving around in an area that you know is served by traditional fire- or hospital-based EMS, it's probably transporting someone from one hospital to another.

If a private ambulance crew rolls by an accident, do they stop?

Depends. The legal concept at work is called "duty to assist." What exactly constitutes a duty to assist varies by state; I could tell you what would qualify in the states where I've worked, but I don't know anything about Washington. The ambulance company may also have internal rules that either encourage or prohibit their employees from stopping in situations where there wouldn't be a legal duty to assist. (I'm speculating here, since I've never worked for a private ambulance company. The systems I've worked in were various shades of public, and they had SOPs that while in uniform or driving a marked vehicle, if you encountered an emergency you would stop and call 911 unless there was a unit on the scene already, although it was up to you whether you would actually render any sort of treatment ... "rendering treatment" generally means that you've signed yourself up for a fair bit of paperwork, so it's generally not something you'd want do unless the situation warrants it.)

You can spend literally hours dissecting something like "duty to assist" or "abandonment" in the context of a particular operating environment or just a single call ... it gets into some complex territory rather quickly. I know of people told to turn in their gear (i.e. were on-the-spot dismissed) from departments for failing to aid a patient in a situation that would have gotten them reprimanded if they had intervened in other places. It a very thorny issue to talk about in broad generalities.
posted by Kadin2048 at 2:40 PM on December 6, 2010 [3 favorites]

In my current city (a suburb of Philadelphia) the fire department I volunteer with holds the license for the basic life support ambulance you ride in on the way to the hospital after calling 911, and provides the two-EMT crew in it. If you need more advanced care, such as intubation or IV medications, a single-paramedic chase vehicle is dispatched to rendezvous with the FD ambulance. This advanced life support car and the paramedic in it are hospital-based. ALS can be automatically dispatched when the 911 call center hears how severe the call will be, or the FD BLS truck can call dispatch and ask for it if a previously simple call deteriorates.

This is completely different from the system I used to work for, which was also in PA, but much more rural. There, a fire department quick response pickup truck would show up and try to stabilize the patient until the private BLS service I used to work for could show up. They had no part in transport, and often had only first responder training (I know you said you know this, but for the benefit of others--in PA, first responder is a 58 hour course of basic first aid skills, as opposed to 140 hours for EMT and about 18 months for paramedic). This was because the fire departments were much more evenly distributed in the area than ambulance stations, but did not get enough call volume to justify the costs of running a full ambulance.

In PA, compared to BLS ambulances, ALS ambulances and chase vehicles are more expensive to license and require a closer relationship with a hospital. Paramedics and EMTs both work under a specific doctor's medical license, but paramedics spend a lot more time talking directly to a doc for orders.

Private transport ambulance crews could stop if they rolled up on an accident, but many BLS transport-service EMTs often don't have any emergency experience at all. In this situation, they would probably do much more help just calling 911. In PA, there is no legal penalty for 911 EMTs not rendering care when off-duty. Most I know would stop at an accident anyway. On duty, a 911 ambulance crew would have to stop and stabilize the patients/give a good report to dispatch, but it is unlikely they would transport a patient if the accident occurred outside of their usual service area.

I'm not too familiar with Seattle, but I hear they have a huge survival rate for witnessed cardiac arrests. I think it has more to do with bystander CPR training than just the ambulance system, though.
posted by skyl1n3 at 2:42 PM on December 6, 2010 [1 favorite]

In addition to the above, some smaller municipalities use the private services to cover nights or weekends when the fire department is understaffed, or when the paramedic calls in sick.

Likely, the majority of the private ambulance services you see will be for transporting people to and from one level of medical care or another.
posted by gjc at 3:13 PM on December 6, 2010

Like skyl1n3 pointed out, in some more affluent suburbs of NYC volunteer ambulance (and volunteer fire) corps provide basic life support (BLS) services for free to their respective townships, supplemented by advanced life support (ALS) private companies that provide paid services to the county.
posted by jameslavelle3 at 5:04 PM on December 6, 2010

Best answer: Specifically to answer your question, read here and here. However, in general, like said above, 911/EMS service depends on your area. There are some rural areas where the ambulance service is all volunteer and you will usually get a volunteer EMT to respond. Mostly in Washington state EMS is run through fire districts (they generally have paramedics and EMTs) however there are some private ambulance services (Medic One and AMR in the Seattle area) that are integrated into the EMS response system. Fortunately in Seattle, our EMS system is excellent. Between Harborview, Seattle Fire, AirLift, and Medic One, the training of EMS providers and coordination of the EMS system is exceptional.
For your last questions, EMS providers, if they just happen upon an accident, will usually stop if there are no other providers there, however they may be very limited in how they can respond as they can't practice outside of their scope of practice (ie: EMTs can't do paramedic level skills) and your average private ambluance EMT will not be able to do extrication. They don't tend to stop if there are already responders on scene unless they are toned to respond (this also varies, depending on the area and scene).
posted by MsKim at 6:29 PM on December 6, 2010

My uncle was an EMT for a private ambulance company in Seattle for over 20 years. Basically, if the call isn't life threatening or critical, they dispatch it to the private companies. However, at least back in the 70s and 80s, if there was a critical emergency and no available aid units in the area, they would sometimes dispatch a nearby private ambulance to try and stabilize the patient until the aid unit could get there. The private companies also transport patients between facilities (transferring hospitals, nursing homes, etc) and basically function as a sort of medical taxi service.

The work sucks, the hours are brutal (12 hours shifts are the norm), the pay is insulting, and the job is dangerous. My uncle was responding to a call back in the 70s and was hit by a drunk driver and broke his neck. He can walk today, but had to have his vertebrae permanently fused. He was also shot at, assaulted, and saw things he said he never wants to see again. He once told me a story about a rape victim he and his partner picked up that worse than any horror movie I have ever seen. You get a serious dose of man's inhumanity to man doing a job like that.
posted by evilcupcakes at 9:46 PM on December 6, 2010

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