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Everything You Need to Know About Ambulances

Kelsey Tyler

In 2014, while driving home from the gym, Edie Weinstein grew dizzy and started sweating. She also felt an intense tightness in her jaw. Heart disease runs in her family, so Weinstein recognized the telltale signs — she was having a heart attack.

But instead of pulling over and calling 911, she decided to drive herself to the hospital. “I thought, I can’t afford an ambulance, and the hospital is less than 10 minutes away,” she says. At the hospital, Weinstein, who lives in Philadelphia, was whisked off to the cardiac catheterization lab. Doctors ended up inserting a stent in her coronary artery, which was completely blocked. Later, hospital staff, friends and family scolded her for driving herself.

“I know now I could have hurt somebody on the road,” Weinstein says. What’s more, in an ambulance, if she’d gone into full cardiac arrest and stopped breathing, a paramedic could have performed CPR on her and administered oxygen. They also could have started an IV, to save time at the hospital, and given her a variety of cardiac drugs.

Uber’s entry into a city reduced ambulance use by 7 percent.

Weinstein, however, wasn’t wrong to fear a sky-high bill. A recent study found that 86 percent of encounters with ambulance services resulted in an out-of-network bill to the patient, making a ride to the hospital a costly experience. To avoid these expenses, it’s not uncommon for patients to forgo ambulance transport; recently, more people have been taking a rideshare to the hospital. One study found Uber’s entry into a city reduced ambulance use by 7 percent. 

For patients, it’s important to understand exactly what emergency medical technicians can do, when an ambulance ride is critical and when it can be skipped.

“EMTs address immediate life threats and transport someone to the hospital,” says Jay Bell, who works as an EMT for a volunteer ambulance company in Mahwah, New Jersey. “We’re there to help, but we’re not doctors or mobile urgent care.”

When should you call an ambulance?

Ambulances are meant for people who are seriously ill or hurt and need immediate medical attention, what EMTs call “life- or limb-threatening.” An ambulance is the right choice if someone isn’t breathing, is unconscious, is experiencing severe bleeding or chest pain, has a serious burn, is having a stroke or heart attack, or may have a spinal injury from a car crash or other type of fall. (That’s just a partial list of scenarios that warrant an ambulance.) Calling an ambulance for a minor injury like a sprained ankle can keep EMTs from answering more critical calls. “If somebody has a heart attack at that same moment, we can’t be there for them,” Bell says.

“It’s really the luck of the draw. Are you going to get the paid company or the volunteer company?”

Bell often gets calls about diarrhea, typically from the flu or food poisoning. If a patient loses control of their bowels in his ambulance, the vehicle is out of commission for 30 minutes while workers decontaminate it. So, if a person is breathing and there’s no life threat, he might suggest they make an appointment with their doctor or go to urgent care instead. Jill Schildhouse, a writer who lives in Phoenix, regrets her ride to the hospital in an ambulance last year. When she dislocated her knee during a press trip at a vineyard in Sonoma County, the woman in charge insisted on calling 911.

“It really wasn’t necessary for me to take an ambulance to the hospital,” Schildhouse says. While the pain was excruciating, her life wasn’t in danger, so she didn’t see a reason to risk incurring a huge medical bill. “Anyone could have driven me.” Three months later, Schildhouse received a $2,000 out-of-network ambulance bill.

What happens when you call 911?

When you call 911, a dispatcher at a 911 call center answers and asks you a series of questions. Is the person unconscious? Are they breathing? The answers you give help determine which ambulance they’ll dispatch.

In many cases, the dispatcher will send the closest ambulance, and that could either be a private or a public one. For-profit companies run privately owned ambulances, while public entities like fire departments run public ones. You probably won’t be able to tell the difference.

“It’s really the luck of the draw,” Bell says. “Are you going to get the paid company or the volunteer company?”

Private companies almost always bill patients. Some volunteer agencies “soft bill” instead, meaning they won’t send outstanding unpaid bills to a collections agency. Then other volunteer agencies won’t bill at all.

Who’s onboard an ambulance and what equipment do they have?

There’s typically one emergency technician and one driver on board. An EMT is the basic certification. They can stabilize and transport a patient using basic equipment and perform interventions like bandaging wounds, performing CPR and administering oxygen. They can’t do more advanced procedures like starting IVs or intubating unconscious patients.

Some states have advanced EMTs, and they can do certain things basic EMTs can’t, like insert an IV line. Paramedics are the most advanced responders. They can give all sorts of medications intravenously, like anti-seizure medications, anti-nausea medications and painkillers (including narcotics).

If a patient needs advanced care — if they’re having chest pain, for instance — a dispatcher may send an ambulance staffed by paramedics instead of basic EMTs. In most cases, the more highly trained the personnel, the higher the ambulance bill. Both EMTs and paramedics need to be re-certified every few years.

A person can ask an EMT or paramedic to take them to a specific hospital, but they won’t always honor the request.

The nonprofit National Registry of Emergency Medical Technicians provides national certification and registration for U.S. EMTs at five levels. Most states have at least partially adopted NREMT certification, but many still follow their own policies and procedures for emergency responders.

Different states have different requirements for the supplies ambulances have to carry. Most stock bandages, cots, patient restraints, defibrillators, oxygen and an abdominal trauma pad, and they’re inspected yearly to make sure they’re properly equipped. In New York, for example, the detailed list of equipment required by the New York State EMS code also includes scissors, sterile burn sheets, tape, a blood pressure cuff and a stethoscope.

What happens when you get in an ambulance?

The EMT or paramedic first secures the scene. Next, they make sure the person’s airway is clear from obstruction and that they’re breathing. After that, they’ll check circulation by taking the person’s pulse.

They then take cervical spine precautions, if necessary. That means the responder will keep a person’s spine aligned if they’ve been in a traumatic accident and are at risk of neurological injury. 

All the while, the responder will ask detailed questions about how the injury happened and what the person is feeling. It’s crucial information they relay to emergency workers at the hospital upon arrival.

Can you choose which hospital you go to, or even decline the ride?

A person can ask an EMT or paramedic to take them to a specific hospital, but they won’t always honor the request. Bell says nine out of 10 times, the answer is no. “You can’t drive past a hospital to go to another hospital if it’s an emergency situation,” he says.

What’s more, hospitals specialize in certain conditions — trauma of varying degrees or stroke, for example. A patient in a severe car accident may need to be taken to a Level I trauma hospital, not their local ER, in order to get the best treatment.

If a person is alert and cogent, and not in a life-or-death situation, their request might be honored, says Mark Billock, an EMT with a private ambulance company in Crystal Lake, Illinois. But first, Billock needs approval from a doctor at the hospital responsible for overseeing all emergency care in the region. (In Illinois, this is called the resource hospital.) 

The patient would have to sign an AMA (against medical advice) form acknowledging that the EMT explained the risks of going to a different hospital — namely, that their condition could deteriorate — and that they understand those risks. If the hospital they want falls outside the first responder’s jurisdiction, another ambulance might come to transport them, and the patient could be billed by two separate ambulance companies.

Many insurance providers also only cover transport to the closest facility that can treat a person’s condition, says Billock, and passing that facility based only on patient preference might mean additional charges.

Injured patients who refuse transport are asked to sign an RMA, which means “refuse medical attention.” If an ambulance arrives and a person doesn’t need help, the ambulance can be “canceled” at the scene, Bell says. Some patients aren’t allowed to refuse an ambulance, though, including those with an altered mental state due to alcohol or drugs, brain injury or psychiatric illness.

So, should you take an ambulance or not?

It depends. For certain injuries, speed is of the essence. A private car or rideshare can’t use sirens or legally go 10 miles over the speed limit like ambulances in many parts of the U.S. can. But with an ambulance taking an average of seven minutes to arrive at the scene, a friend or family member’s waiting car could still get you to the hospital faster.

Gunshot and stabbing victims are far less likely to die if they’re taken to the trauma center by private vehicles rather than emergency medical services, according to a recent study from the Johns Hopkins University School of Medicine.

Weinstein in Philadelphia changed her tune after her heart attack. A month later, she got a kidney stone at a conference. She had better health insurance, let organizers call 911 and was happy to be in the back of an ambulance connected to an IV and monitoring equipment. “Fortunately, there was only a small copay,” she says.

Bell recommends that people educate themselves on how their local EMS is set up before an emergency happens. Are the majority of ambulances where you live volunteer or private companies? “You can’t change who picks you up,” Bell says, “but if you know what the scenario is likely to be, you’ll have less anxiety in an already anxious moment.”

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