When San Jose and Santa Clara entered the ambulance business in 2001, city officials declared the new service would be needed more than 400 times a year -- each time a county ambulance couldn't reach critically ill patients fast enough.
The cities spent more than $1.9 million to acquire 10 vehicles. But it's turned out that their ambulances are almost never used.
Since the service began 32 months ago, the city ambulances have transported just 23 patients -- an average of about one patient a year for each ambulance. One of San Jose's ambulances, bought for $151,550 and stationed in Almaden Valley since mid-2002, has never taken a patient to a hospital.
And one high-profile patient who was transported didn't need the city service at all. That was San Jose Mayor Ron Gonzales, who suffered a stroke while delivering his State of the City speech in January. He was taken to the hospital in a city ambulance even though a crew from Santa Clara County's ambulance contractor was standing by to transport him. A San Jose fire official ordered the county ambulance instead to create a diversion for the media.
While pitched as a way to improve critical medical care, the cities' ambulance initiative also was part of a broader effort by fire departments concerned that declining numbers of fire calls could lead to fewer firefighters. Today, even though the ambulances have been used only rarely, fire officials maintain the cost was justified for the lives that have been saved and as a back-up resource in case of a disaster.
In Santa Clara County, decisions on patient transport are more complicated than looking at which ambulance arrives at an emergency call first. The city ambulances are used sparingly because they must operate under a contract that gives the county's contractor, American Medical Response, the responsibility for local ambulance service -- assuming it can provide it quickly.
Since the cities put their ambulances into service, American Medical has arrived on almost every emergency call before the patient was ready to be taken to the hospital. Sometimes a city ambulance reaches the scene earlier, but once American Medical arrives, the city ambulance is not used. In most cases, a slight delay in an ambulance's arrival presents no problem because paramedics riding on fire engines provide the initial medical care.
The two cities established their ambulance business after a long -- and mostly unsuccessful -- political and legal battle with the county. The fire departments in San Jose and Santa Clara had tried to take over all ambulance service in their cities in the mid-1990s but were blocked by county officials seeking to preserve a regional ambulance system and by American Medical, which wanted to protect its business. The business is good: With each transport comes the right to charge a patient a fee that's now $839.
State law was on the county's side. So the cities in 2001 settled for a deal in which they could add a handful of ambulances for their fire departments to supplement the regional service, as long as the cities paid for them and opportunities for their use would be limited.
``I don't want to say that it's too restrictive, because I negotiated it. But it's too restrictive,'' said San Jose Fire Chief Jeff Clet, who led the department's entry into the ambulance business. ``It was a negotiated item because there was a fear on the part of AMR that we were putting these in place to replace them.''
Clet said that wasn't the city's interest.
``We wanted the ambulances in place to take sick people to the hospital when we needed them.''
Clet acknowledges he overestimated the need. But both he and Santa Clara Fire Chief Phil Kleinheinz say American Medical improved its response once the cities got into the business.
``Their service level came way up,'' Kleinheinz said. ``For every time they're not on the scene that we're transporting, that was revenue they wouldn't get, so obviously they wanted to protect their income stream as much as possible.''
American Medical acknowledges only that it has added ambulances to remain in compliance with its county contract, which requires reaching 90 percent of urgent calls within 12 minutes. The company collected $46.6 million in emergency-transportation fees last year. The company keeps 10 to 32 ambulances operating in the county, depending on the time of day and anticipated demand.
Despite the city ambulances' infrequent use, the fire chiefs say they've incorporated the ambulances into their response schemes in ways that make them more useful than they appear.
Clet points to an example March 17, when an Evergreen-area woman, 37-weeks pregnant, was suffering a life-threatening blood loss and needed to be transported to the hospital. She was taken by a department ambulance to Regional Medical Center, where she delivered by caesarean section and both the mother and baby survived.
Four of San Jose's six ambulances -- including one reserve unit -- have a dual use. They are equipped to serve as the second vehicle of a truck company, carrying floodlights, an electric generator and rescue equipment. Every San Jose truck company has a second unit, and Clet said each of these combination ambulances cost only about $30,000 more than if they had been acquired without the big box in the back to transport patients.
Clet acknowledged ``it's a very legitimate question today'' whether San Jose's two other ambulances -- which don't have a secondary purpose -- have been worth the cost. But he said he believed that they would be in greater demand as the city continues to grow.
Other cities in the county had the chance to go into the ambulance business in 2001 but passed, believing the benefits did not justify the cost. Palo Alto has had its own ambulances since 1976 and is not part of the county system.
``We felt we could address our needs through the contract with AMR and the county in regard to reasonably adequate emergency transportation service,'' Mountain View City Manager Kevin Duggan said. ``We did not identify a specific deficiency that we needed to address.''
Gonzales said he's satisfied that San Jose's investment in ambulances has been worthwhile.
``This was an opportunity to add to our inventory of equipment that can be used on a day-to-day basis or in those rare instances in San Jose or the region where they'd be needed'' for a major natural disaster or terrorist attack,'' he said. ``It's better to have it and not need it than not have it.''
It appears the ambulances were not needed when Gonzales became ill while delivering his January speech at the Center for Performing Arts.
The city ambulance did reach Gonzales first, in part because of a coincidence: One of the San Jose crews happened to be in the audience. The crew began to leave when the speech was suspended, but then it overheard that there had been a call to 911 for the mayor. The ambulance crew turned around and reached the mayor within three minutes.
The mayor's illness at that time was unknown, and an American Medical ambulance was dispatched to the scene as a low-level emergency, without lights and sirens, arriving 12 minutes later.
When the American Medical crew arrived, a fire department battalion chief, Kevin Conant, told them they would ``act as a diversion in case there was media interest,'' according to a report by the American Medical crew.
Conant said in an interview that he suggested the diversion because he arrived after the mayor became ill and did not know what had happened. Among the possibilities Conant considered, he said, was that the mayor had been attacked and a diversion might be needed for security reasons.
Ultimately, said Battalion Chief Jim Stunkel, fire department personnel decided to take the mayor to the hospital ``in an effort to protect his privacy.''
Flap over mayor
American Medical officials later argued that use of the city ambulance was inappropriate because their ambulance reached the mayor by the time he was ready to be transported. The issue went to the county's emergency medical services chief, Bruce Lee, who determined that use of the city ambulance was ``in technical violation'' of the agreement with the county.
But Lee decided in a March 19 ruling to waive a $5,000 penalty because of the ``unique and extenuating circumstances of the event, including issues pertaining to scene management and the desire of the fire personnel to provide appropriate patient care.''
Gonzales said he knew nothing of the decisions about which ambulance would transport him.
``All I know is I got sick and ended up in the hospital,'' he said. ``I'm grateful for the great assistance I got from the fire department. Everything else was their call.''