ON A RECENT weekday, two paramedics sat on the cots they almost never have time to sleep on at their neighborhood fire station.
Their shift had just begun, and they jokingly bet on how many runs they'd make that day. But before they could finish the thought, a bell rang.
First run. Time to go.
They hopped into their ambulance, hit the sirens and raced to the scene. Someone had reported a man who was high on drugs, and the paramedics persuaded him to climb in the ambulance and go with them to the hospital.
After dropping him off, the medics told the dispatcher they were available. A minute later - before they got out of the parking lot - they had a new assignment: a man with difficulty breathing.
On and on they went for the rest of their 12-hour shift, rarely getting time to catch their breath.
Meanwhile, back at the station, a crew of firefighters spent much of the night watching movies, checking Facebook and sleeping. Undoubtedly, the firefighters have busy days as well. And no one would argue that the city shouldn't have firefighters ready for when the worst happens.
But the new reality for the Philadelphia Fire Department, and in other cities, is that the vast majority of the work is done by medical responders.
Because of the exodus of industry and advances in fire prevention and in construction practices, the number of structural fires has been decreasing for decades. And due to an aging population and behavioral factors, medical emergencies have skyrocketed.
Many cities have adjusted to this new reality. Philadelphia, by most accounts, has not.
Not Enough Medics
The response time for medical calls is far greater than the response time for fires, in large part because there simply aren't enough paramedics to fill the need.
A few times a week, the department is so overrun by medical emergencies that no ambulances are available to respond immediately to 9-1-1 calls, according to several paramedics.
Of the 276,939 emergencies to which the Fire Department responded in 2012, 84 percent were for medical calls. Yet the city employs 248 paramedics and 1,912 firefighters.
Fire Commissioner Lloyd Ayers said he hopes to increase the ranks of paramedics to 300 in the coming years. But even with those reinforcements, Philly's emergency-medical service, or EMS, will likely remain overworked.
Response times for fire incidents are generally on par with standards set by the National Fire Protection Association, according to a year-old report by the city's financial watchdog, the Pennsylvania Intergovernmental Cooperation Authority. But on medical runs, for which the national benchmark is to arrive within 5 minutes 90 percent of the time, responders get there in that time frame only 45 percent of the time, the report said.
One reason: Philadelphia's paramedics are likely among the most overworked in the country, according to Jeff Zack, a spokesman for the International Association of Fire Fighters' U.S. headquarters.
"I don't get a break. My body just feels like it's so tired," said one paramedic from a different station who, along with about a dozen others, agreed to talk with the Daily News only anonymously because the department bans them from speaking with the media without approval. "I'm picking up these people, carrying them down the steps. We do a lot of physical work besides the fact of doing the [mental] work ... with the adrenaline pumping when you're trying to save someone."
Many units here run 6,000 to 8,000 calls per year - more than double the IAFF's national standard of 2,500 to 3,000.
Medic Unit 2, at Kensington and Castor avenues, which makes roughly 9,000 calls per year, is the single busiest unit in the country, Zack said.
"It's wrong and dangerous for the workers, and the only thing it can do is increase response times and ensure that patients are getting tired, overworked medics," Zack said.
Aside from adding personnel, the administration said it is pursuing policy changes that will improve EMS performance. But the road to reform is littered with pitfalls: a venomous management-labor relationship and a dominant firefighters' culture that overshadows the needs of paramedics.
A slew of advances that have been adopted by many departments, such as cross-training between firefighters and paramedics or a dispatch system that prioritizes more serious 9-1-1 calls, haven't happened here.
Ayers said some of those reforms are on the way.
But for the city's paramedics, many of whom feel overworked and underappreciated, there is a fundamental problem with the way the department sees its role in the community.
"It's a fire department run by firemen, and sometimes they don't realize they're a paramedic department," said one paramedic. "They think they're a fire department that does EMS. And they're not. They're an EMS department that does fires."
Many paramedic runs are for seemingly frivolous 9-1-1 calls, they said. They rattle off classic cases, like an overweight man who called 9-1-1 because he couldn't reach his TV remote.
Under current policy, the city responds to all medical emergencies without prioritizing ones that are life-threatening or time-sensitive.
Ayers said paramedics will soon see relief on this front: The city is working with a contractor to develop a call-screening system for its 9-1-1 dispatchers that he hopes will make sure EMS responders are being used for true emergencies.
The system's launch will coincide with an $800,000 public-awareness campaign that will discourage unnecessary 9-1-1 calls and, Ayers hopes, show paramedics that they are valued by the department.
He said he's also working to integrate the firefighters' and paramedics' work lives to make it a place "where both cultures are respected equally, 'cause it's one Philadelphia Fire Department, and paramedics, emergency-medical technicians, they are a component of that."
In a move that has so far been highly unpopular with the work force, the department recently changed firefighters' schedules from alternating 10- and 14-hour shifts to across-the-board 12-hour shifts, which matches paramedics' schedules.
"Now, you're more familiar with who you're going to be working with and you're going to be trying to go through that whole reengineering process of the system where we can have a tighter bond," Ayers said of the shift.
Additionally, the administration is interviewing candidates to be the city's first deputy commissioner for EMS operations. Over time, the elevated status of the top-ranking EMS officer could give paramedics more leverage in the department.
But even with these changes, Philly has a long way to go to catch up to other cities, where fire departments have been shifting away from the 1950s model.
One paramedic pointed to the department in Phoenix: "They know where the bread is buttered."
Phoenix has roughly the same population as Philadelphia, but, like much of the West, many of its buildings are newer, making structural fires less frequent. Additionally, it has a large senior population, driving up medical calls.
As a result, the city began adjusting to a medic-centric system decades ago. All fire trucks are staffed with paramedics, so the department does not have to depend on ambulances for routine medical runs, said Capt. Jonathan Jacobs, spokesman for the Phoenix department.
Instead of sending some vehicles on fire runs and others on medical runs, dispatchers judge calls by their severity. For time-sensitive emergencies - medical or fire - the department responds to almost all calls within 4 minutes, 30 seconds, Jacobs said.
"Our philosophy is, if you call us - it doesn't matter if you have a structure fire, heart attack, difficulty breathing - we only have to send one fire truck and you get a much better service" because every truck has a paramedic, he said.
Departments like Philadelphia's, Jacobs said, are inherently inefficient because medical runs account for so much of the activity.
"A system like that will just eat itself alive," he said. "They're always scrapping for fires instead of bringing it together."
Ayers said a Phoenix-like system, which could require EMS training for firefighters or staffing more fire vehicles with medics, would be "a long, arduous process, a costly process" for Philadelphia, although the city hasn't ruled it out.
City Controller Alan Butkovitz's office released a report in late 2007 that highlighted many of the issues that still plague the city's paramedics. It recommended such solutions as more ambulances and a more advanced system for 9-1-1 dispatch, in which medical professionals would handle some emergencies over the phone.
Butkovitz said the administration is now taking "positive steps" but he doesn't understand what took so long.
"Philadelphia is way behind the rest of the country in running an efficient paramedic service," Butkovitz said.
Ayers, who is set to retire in 2014, said pushes for reform have been hindered by the poisonous relationship between the Nutter administration and the firefighters' union, International Association of Fire Fighters Local 22, which includes the paramedics and has been working without a contract since 2009.
The union has won a series of legal battles that would award it retroactive raises and other benefits. But the administration continues to appeal those decisions, saying the city simply cannot afford it.
"It's tough because right now it's some labor unrest, and that sits at the base of things," Ayers said, adding that his successor "is going to have to make decisions based on how to move forward in a way that's fiscally responsible - we can't be wasting folks' money - and that's ethically proper. That means getting out there, doing the job."