‘ETA should not exceed 20 minutes’

Muscovites are waiting longer than ever for ambulances during the coronavirus pandemic, but the reasons aren’t as obvious as you’d think

Residents in and around Moscow complain that they now have to wait hours or sometimes even days for paramedics to come when called. Doctors admit that ambulance crews are currently understaffed because many emergency responders have contracted coronavirus or been placed under quarantine. Meduza spoke to multiple Moscow paramedics and studied the rules dispatchers and physicians use to determine who gets help and who waits.

On May 8, 2020, Meduza reported on Alexey Titov, a 42-year-old officer in Russia’s Federal Protective Service killed by COVID-19. His friends say he tried to call an ambulance twice before he died. Meduza has now verified this information. On May 13, the Moscow city department responsible for the capital’s emergency call center confirmed that Titov’s phone number placed a call to 1-1-2 on the morning of April 25 and his wife later called from her own phone, again requesting an ambulance. She left her husband’s number as a return call number. Titov’s friends told Meduza that he was refused hospitalization. Finally, on April 28, colleagues collected him in an ambulance from the Presidential Regiment’s fleet and brought him to a hospital operated by the Federal Security Service, where he died two days later.

Meduza has learned that Alexey Titov is hardly the only person in Moscow with severe coronavirus symptoms or otherwise urgently in need of hospitalization who’s encountered problems with emergency responders. Meduza’s readers in and around Moscow have shared their own stories. “I was sick after three weeks of isolation. I live alone now and I work from home. On April 16, I had a temperature of 37.2 degrees [98.96 degrees Fahrenheit]. On the ninth day, I called 1-1-2. Just in case, I got ready for the hospital,” recalls a woman named Marina. “The doctors didn’t come. They called and made sure that my voice still sounded okay, praised my immune system, and advised me to contact a health clinic, if things got worse.” Finally, tired of waiting for an ambulance, on the 16th day of her fever, cough, chest pain, and loss of smell, Marina left her home and went to a private clinic, where she was promptly diagnosed with double pneumonia and damage to a quarter of her lung tissue.

“On April 22, I started getting symptoms: a fever, I was burning up, headache, and a lot more,” a man named Ivan told Meduza. “I called a DMS doctor, who said, ‘You know, we don’t have any covid tests, but you probably just have a cold.’ So then I called the OMS for an ambulance and — believe me — it was damned hard. The paramedics recommended that I ride with them to the nearest outpatient clinic for a CT scan, plus a covid test. I’ll lay this out so you understand the tension here: you can’t get a test through DMS, but if you want to get tested through OMS, you first need the paramedics to come to your door, and they might simply refuse over the phone. And then, if you’re really lucky, they’ll take you to an outpatient clinic for a test because the ambulances don’t carry the tests, either.”

Why are people being denied hospitalization? It’s most likely due to the standards that guide dispatchers and ambulance crews.

How quickly are ambulances supposed to respond to emergency calls?

“The time it takes an ambulance crew to reach a patient to provide emergency medical care should not exceed 20 minutes from the moment the patient calls. In localized guidelines, ambulance crews’ time of arrival can be reasonably adjusted, considering transport accessibility, population density, and the climatic and geographic features of regions in accordance with the State Guarantee of Free Medical Care to the Citizens of the Russian Federation.” (Appendix No. 2 to the Procedures for Emergency Response, which include emergency medical care, enacted on June 20, 2013 by Order No. 388n, paragraph 7, of Russia’s Health Ministry.)

Since mid-April 2020, Moscow ambulance services are regulated by Health Department order No. 387 “On Measures for Organizing the Work of the Moscow Municipal Enterprise ‘Puchkov Ambulance and Emergency Care Station’ With Patients Diagnosed with COVID-19 or Suspected of Contracting the Disease.”

These orders stipulate that all 1-0-3 dispatchers responding to calls involving acute respiratory viral infections are required to ask patients a series of seven questions from a prepared list, for example: “Are you experiencing shortness of breath?” “Are you experiencing a loss of smell or taste?” “Do you experience chest pain or discomfort when breathing deeply?” and so on. If patients answer yes to only one of these questions, they are advised to contact a local outpatient clinic. If callers give two or three affirmative answers, dispatchers can send an emergency medical crew to provide urgent care. If patients answer yes to more than three of the seven questions, the dispatcher transfers the call to an ambulance crew.

Medical crews vs. ambulances

Both emergency medical crews and ambulance paramedics respond to 1-0-3 calls, but they are two separate divisions. Dispatchers determine which responders handle different patients, based on the severity of their conditions. Emergency medical teams are typically connected to local outpatient clinics, responding to patients in non-life-threatening situations without need of urgent hospitalization. If a patient’s condition turns out to be worse than expected, medical crews and call ambulances themselves.

When they arrive to treat patients, ambulance crews must independently assess the severity of their symptoms based on the “National Early Warning Score” (NEWS) special protocol, which has seven parameters, including blood oxygen saturation, body temperature, respiratory rate, changes in consciousness, and so on. Points are “awarded” for each parameter and the total score determines how paramedics proceed. A one-point score corresponds to a mild infection and the patient is advised to contact an outpatient clinic. Scores between two and four points signify mild cases and ambulance crews are advised to bring patients to an outpatient clinic for CT scans to check for pneumonia. Scores of five or higher indicate a severe infection requiring hospitalization.

If a patient with a moderate or severe respiratory infection (scores between three and five) refuses to go to a clinic or hospital, paramedics are required to collect a swab and transfer the patient’s information to emergency medical services and 1-0-3 dispatchers, to ensure that the patient is placed under observation and contacted later to monitor their condition.

“In fact, it all depends on how much work they’re willing to do,” Andrey, a deputy operations head at a commercial ambulance service, told Meduza. “You can put down three or four points, take the patient to a clinic, and be ready for the next call. If the patient’s condition suddenly worsens at the clinic, that’s a separate call for another crew. Or you put down five points and take it easy at the end of your shift, waiting in line at the hospital. Every crew makes their own decision.”

Alexander says he believes the protocols guiding ambulance work are reasonable measures to keep Moscow’s emergency response network from collapse. He especially approves of the decision to open outpatient CT scan centers, saying that clinics were hit hard by the coronavirus outbreak early on. “More than half the primary-care physicians were soon out on sick leave and the outpatient clinics are understaffed, which is why the diagnosis quality has been so lousy,” he says. “Plus, there are the instructions to hospitalize everyone so they don’t clog up the local clinics. Nevertheless, opening round-the-clock outpatient CT scan centers kept Moscow ambulance crews from the bottlenecks that paralyzed emergency responders in the Moscow region.”

What the paramedics are saying

Based on accounts from patients and their relatives, the ambulance situation outside the capital is far worse. People have waited several hours or even days for paramedics, sometimes giving up and driving to clinics themselves. Emergency responders in the Moscow region operate under the same rules and protocols as in the city, but regional officials didn’t formally enact these guidelines until April 24, ten days after the capital.

Last month, Meduza reported a lack of PPE among ambulance crews, who have complained to local health officials and their union representatives. The same health workers say coronavirus has also caused massive personnel shortages, with doctors and paramedics home sick, extending wait times for ambulances. “We’re essentially dooming people to disability,” a paramedic named Snezhana Murashova told Meduza, though Oleg Kakurin, the chief physician at the Moscow region’s ambulance response station, says he hasn’t received any complaints from paramedics.

Ambulances have also had to contend with enormously long lines when dropping off patients at emergency rooms. The Moscow Health Department’s containment measures require hospitals to run a large battery of tests on anyone admitted with symptoms suggesting community-acquired pneumonia or coronavirus. Testing each patient can take several hours.

On social media and in Internet forums devoted to healthcare workers, Moscow doctors and paramedics frequently complain about the challenges and obstacles they face on the job. The situation, however, isn’t hopeless.

Meduza reached out to several health workers who have spoken out online. One commercial ambulance paramedic named Alexander says city officials managed to restore some order by opening outpatient CT scan centers and recruiting private medical clinics to hospitalize spillover patients. For some reason, Moscow regional officials have declined to work with private paramedics, despite reported cooperation with such enterprises at local mass events before the pandemic. Regional Health Ministry officials did not respond to Meduza’s questions about coordination with commercial medical services.

A paramedic named Dmitry told Meduza that ambulance stations have been operating skeleton crews, pairing a single medical worker to each driver, instead of running standard three-person teams (a driver, a paramedic, and a doctor). Dmitry also says doctors didn’t take the disease seriously at first and neglected to wear PPE when responding to calls. This later aggravated personnel shortages, of course.

Vyacheslav, another Moscow paramedic, confirms that ambulance crews were short-handed earlier in the pandemic, but says the situation has improved with better rules and protocols and as more hospitals have been converted to treat coronavirus patients.

According to Vyacheslav, emergency dispatchers have also been hit by the coronavirus, leaving call centers understaffed, which means paramedics often have to wait as long as an hour before they’re cleared to hospitalize a patient whose condition is rapidly deteriorating. Before getting to that stage, emergency responders are also burdened with large amounts of paperwork needed to track and isolate people cohabitating with suspected coronavirus patients.

“Just imagine you answer a call and there are 10 [Commonwealth of Independent States] nationals there and you’ve got to write out directives to all of them as contact cases. How much time is that going to take?” asks Vyacheslav.

Ambulance crews also have to deal with another less expected challenge: ferrying quarantine violators arrested by the police to medical observation centers. Vyacheslav says there are no formal guidelines regulating this work — it’s just something law enforcement agencies have improvised as part of the city’s quarantine.

Story by Alexey Yablokov and Alexey Kovalev with assistance from Maxim Solopov

Summary by Kevin Rothrock