9 Letters away from a solution – An EMS 2.0 update from San Francisco

I’ve been going about it all wrong.


Here I was scouring the laws, policies, regulations and statutes looking for a way to get alternate transport vehicles, like vans, SUVs and cars classified as ambulances.

Turns out all levels of regulation are quite clear on what an ambulance (the 9 letters, in case you’re wondering) is.

It starts at the State level defining an ambulance (I’m paraphrasing these) as a vehicle modified to accommodate a stretcher and staffed by 2 people, at least one of them an EMT-1 and that meets all local standards for an ambulance.  So that kicks the details to the local EMS agencies.  I’m OK with that, let the communities decide what specifics they need.  Oh, but there is the 2 person standard and the stretcher part I need to change.

The California Highway Patrol has standards for a vehicle to be LABELED ambulance and allowed to violate certain aspects of the vehicle code by using red lights, siren and blocking the right of way etc.  It requires a forward facing red light, distinctive paint, a cot and 2 people.

Dang it.

Then the County Health Code breaks down an ambulance and a routine medical transport vehicle, both requiring cots and 2 people.  This is looking bad.  So far I have to change a state law, a vehicle code and a County Health Code.

The local EMS Agency is specific on the staffing requirements of a BLS and ALS ambulance, equipment for first response vehicles (do all ALS first response vehicles really need a long spine board?) and are also charged with certifying that all ambulances in the system comply to the standards.

I have a huge uphill battle if I want to start transporting people in something other than a 2 person ambulance.

Or do I?

What is surprisingly lacking in all the statutes I’m reading are 2 things:  The definition of a patient, and a definition of what a patient uses to get to the hospital.

It appears the automatic default is that a patient will go via an ambulance and vehicles carrying those 9 letters are well regulated, and for good reason.  But what about when we let folks refuse transport, then they climb in a car and go to a hospital anyways?  Is that drier violating the state law, vehicle code, County Health Code and local ambulance ordinance? Of course not, silly, it’s not an ambulance.

It’s not an ambulance.

I’ve been going about this all wrong.  A complete 180 is in order.  Instead of trying to wiggle my solution into a decades old understanding of 9 letters, we could simply exist without them.

This theory applies only to my pilot project of course, the 9 lettered certified ambulances are still meeting all local, state and applicable laws, but now imagine being able to call the company taxi and send the person who meets criteria in something not labeled ambulance and they get the care they need.

Won’t someone think about the billers?!

Oh, I forgot to mention 1 little law that does go against my idea: Medicare part B.

Medicare part B is the legislation that looks retroactively and decides if the ambulance was really necessary and reimburses accordingly.  This is the main reason so many systems tell their practitioners not to walk patients to the ambulance like I do.  They’re likely not going to pay you for that trip.

So why are we still making the trip in the most expensive, regulated manner possible?

Because of 9 little letters.

Medicare has strict definitions as to what makes a BLS and ALS ambulance and gives subscribers guidelines as to what is and is not covered for reimbursement, even being as specific as to where you are when we declare you dead.  Another reason some agencies transport all cardiac arrest patients.

Turns out the folks who would meet criteria for a retriage to alternate transport wouldn’t be eligible to have Medicare cover the bill anyways.  So why not arrange for alternate transportation at far less cost?  It’s a cost more likely to be recovered and freeing up the ALS ambulance to find another paying customer patient in need.


I was always told there was a big law somewhere telling us we had to do things a certain way.  And there is, if you want to keep doing things the same way.

There’s still a lot of research required and permissions to get, but the biggest blockade to my desire to introduce alternate transport options is gone.

Just leave out those 9 magic letters.

Agree? Disagree? Have something to add? Why not leave a comment or subscribe to the RSS feed to have future articles delivered to your feed reader?

5 thoughts on “9 Letters away from a solution – An EMS 2.0 update from San Francisco”

  1. The main reason we still make the same decisions is because all the rules are there to make sure we do, despite common sense sometimes.  I’m calling for a revolution. You guys in?

  2. Years ago we enacted legislation to protect our patients, improve professionalism, and improve the standards of care. I’m old enough to remember the shoddy ambulance practices that existed here in Portland. We had the best of intentions – we wanted to get rid of those funeral home operators who were only trying to squeeze a little more profit out of their vehicles. We wanted people to get the best of care. We wanted to stop the crazy madness of call jumping, fist fights over patients, and scoop and run transport – without any standards.

    Interestingly, in those days, we, the paramedics, could refuse to transport someone who didn’t need an ambulance – it wasn’t in the protocols, but it was easy to do. Also, most of us really, really cared about being professionals, and we didn’t really need these regulations.

    Now, 35 years later, those laws are cast in stone. Most, if not all of the shoddy ambulance operators have sold out and moved to warmer climates, and the profession has changed – substantially. Now, those concrete laws are like shackles around our feet. Eight minute response time requirements are only needed for a small percentage of our calls. Eight responders on every call – the same.

    There needs to be changes, but it feels very daunting to even begin that process.

    1.  The regulations are certainly worthy for emergency treatment and transport of the sick and injured. Unfortunately, that’s less and less of our business, as you know.  My desire to add onto that history by editing it will now lead me to create my own.
      Daunting sure, but necessary.  Just like the daunting challenges that faced the times you speak of.
      Thanks for reading.

  3. Here in Oregon we have what are called “Rapid Response” vehicles that are similar to what you describe. Its just one paramedic per unit and they handle all the low risk calls such as MVA’s with unknown injury and what not. They can’t transport though (which sucks, REALLY sucks). Only one agency has invested in it so far but it has been a huge success here. Something like that but with the ability to transport patients would be great and should be implemented everywhere. It would save so much time, money and resources. If your curious Ive included a link to the YouTube video that goes a little more in depth with it.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>