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. Last Updated: 07/27/2016

On Call

Lying in bed in his tiny Moscow flat, Nikolai is bleeding. He has been bleeding since the previous evening when, after having too much to drink at his wife's birthday party, he smashed his hand through a glass door in the kitchen.

Dressed in a bathrobe, Nikolai's wife tries to convince him to get dressed and go to the hospital, where they can tend the deep wound in his wrist.

"Please, do it for me. Can't you see I'm not feeling well myself? My blood pressure is up," begs the woman in her late 50s.

But 56-year-old Nikolai is too drunk to understand. Instead, he answers her coaxing with threats.

"I imagine what a brothel you'll make of my house if I go, you bitch," he replies. "But you'll see what I'll do to you when I'm back ... Where the hell are my socks? Can you hear me, you bitch?"

For the next 40 minutes Nikolai continues to curse his wife, dressing and undressing several times - unable to decide whether or not he wants to go to the hospital. Throughout the exchange Yelena Bogomolova, the ambulance doctor called in to tend Nikolai's wounds, sits by patiently.

Bogomolova tries to convince Nikolai that his injury is serious and needs to be examined by a surgeon at the clinic, but she, too, eventually gives up. She changes the bloody bandage on Nikolai's swollen wrist and, before leaving, asks Nikolai's wife to sign a form indicating his refusal to be hospitalized. The bleeding is unlikely to stop, Bogomolova says, and Nikolai's wife will probably call 03, the city's ambulance service, again in a few hours. The next ambulance team will come back to hear more swearing and to witness the same scene repeat itself.

For Bogomolova and the 10,000 medical professionals who work for the municipal ambulance service, Nikolai's case is fairly typical. Infact, Bogomolova says she is lucky when her team only handles one such call during the course of their 24-hour shift. "It could be much worse," Bogomolova says on the way back to her unit's office, which is connected to the Sklifosovsky first aid hospital in central Moscow. "Sometimes we arrive to find both wife and husband drunk, unable to explain who called the ambulance and who needs medical attention."

Dr. Bogomolova works for the service's central ambulance unit, the oldest in town, operating for almost 80 years. The central station is only one of 52 of the network's units scattered around the city.

For years the municipal ambulance service has been the target of anger and ridicule. Patients complain the doctors are rude, cynical and indifferent to their suffering. They are criticized for never arriving on time and never having the right medicine. One of the most prevalent complaints is that ambulance doctors are notorious extortionists, demanding money from patients before they will provide the services they are required to perform for free. The professional skills of the ambulance doctors are also called into question. Even within the medical profession they are frequently looked down upon - seen as losers who fail to become real doctors in other medical fields.

But despite all the public criticism, 03 still carries out 6,000 to 8,000 calls a day and remains the only option for hundreds of thousands of Muscovites for emergency care. Unlike private ambulance companies that target patients able and willing to pay for their services (see page 11), 03 deals with those who cannot afford to pay - among them the city's homeless.

Igor Elkis, a 39-year veteran ambulance doctor who now heads the first aid service, is aware of the criticism, but he shrugs it off as part of his job.

It is only natural, Elkis says, for society to scold them: "We turn up in places where there is blood and pain, and minutes seem to last for hours for people who are in trouble."

Financed by the Moscow city government, the ambulance service has 840 vehicles and employs 10,500 doctors and paramedics, but they suffer staff shortages of some 1,300 medical personnel, Elkis says.

The shortage is a relatively new phenomenon. In Soviet times ambulance doctors were the best paid of their profession, and therefore more young doctors were eager to enter the service. But now salaries have leveled off with those of doctors in other fields. The base salary of an ambulance doctor is around 1,200 rubles ($49). Many doctors decide to pull extra shifts to make ends meet, but even with the overtime they cannot expect to earn more than 2,300 rubles ($94) a month.There is a joke popular among the ambulance doctors, Elkis says: Those who work for just one salary do not have money to buy food, while those making two salaries do not have time to eat.

The drop in salary - as well as the introduction of private ambulance services that offer better pay and work conditions - has contributed to the declining prestige of the ambulance doctor.

"I was at a graduation ceremony of one of the medical schools recently and was surprised to find that of 300 graduates only 12 people chose to join the ambulance service," Elkis says, adding that those who did opt to join were former paramedics who had worked for 03.

But there is at least one advantage to ambulance work. Doctors enjoy a more flexible schedule that allows them to spend more time with their families or take other jobs to earn extra money. For example, Bogomolova used to work in a clinic as an anesthesiologist, but when she went back to work three years ago after the birth of her son she transferred to the emergency service, where employees work eight 24-hour shifts a month. Now Bogomolova spends one day on the job and has the next three off.

For Alexei Danilin, the draw to the city ambulance service was not the flexible schedule, but the challenge of the job.

"An ambulance doctor has nothing but an EKG machine and a case with medicines. That's all we have to figure out what's wrong with the patient and try to help him," says the 29-year-old toxicologist. "The job is tiresome, intense and physically demanding."

An intensive care doctor by training, Danilin has been working for 03 for four years. He rides in a specially equipped Mercedes van, bringing those who overdose on drugs or attempted suicide back to life.

"Not a single druggie has died in my ambulance yet," Danilin says proudly.

In addition to his work in 03, Danilin also works at a private clinic taking care of drug users. The amount he makes there in one 24-hour shift is equal to his monthly salary, but he has no plans to give up his city job.

"Ambulance work sucks you in," Bogomolova says as she tries to relax between calls with a cup of tea. She takes refuge from the bustle of the corridor outside - where dispatchers take emergency calls and pass on orders to the medical teams - in a room with rows of arm chairs that doubles as a changing room and a place to eat in between emergencies.

"A job at a hospital would seem like a health resort after 03," Bogomolova says, adding that her work at the service has made a real doctor of her.

Ten minutes later the dispatcher calls out 27, the number of her team, and she is on her feet. Together with paramedic Grigory Asriyan, Bogomolova heads for the old shabby RAF van that is ready to take them to a new patient: 76-year-old Anna Dmitriyevna, who is blind and suffering from stomach pains.

"Daughter, I want to die," the old woman tells Bogomolova, asking her for a pain reliever.

Bogomolova is puzzled over the diagnosis. The woman is showing symptoms of three illnesses: pneumonia, appendicitis and pancreatitis and requires a more thorough examination in a clinic urgently.

But even at the doctor's insistence, Anna Dmitriyevna refuses to go to the hospital. Annoyed, Bogomolova departs for the office, where she arranges for a surgical team to be dispatched to the patient's house for further consultation.

"I hate cases like that. How am I supposed to help her if she is so stubborn?" Bogomolova exclaims during the ride back to the station. Time, she says, does not permit her to be more tolerant.

The pressures of the job - and those of the pocketbook - take their toll on the ambulance doctor. And these pressures are often passed on to their patients.

Take, for example, Larisa, a 19-year-old linguistics student who fell ill one night. Her mother called an ambulance around 3 a.m., after Larisa had been suffering from a severe headache for the entire day. The ambulance arrived around 45 minutes later, and as the young doctor started measuring her blood pressure, the girl started to cry - frightened that there was something really wrong with her. Larisa recalls the doctor's response.

"Look, baby. It's 4 a.m. Don't you think it's a bad time for your hysteria," the doctor said, clearly annoyed by her tears. He said he would give her a shot to make her sleep and that she could go find out what was wrong with her at the clinic in the morning.

Then - his breath smelling of alcohol - the doctor spent the next 10 minutes trying to find the vein on her arm.

"I was sure he would miss the vein, his hand was shaking," Larisa says. "I stopped crying immediately because I realized I had to watch him closely to make sure he did not injure me."

Stories of doctors drinking on the job or treating patients rudely are common among those who rely on the city ambulance service. Some callers claim that the 03 doctors will do nothing to help you if you do not offer to pay them. Yevgenia Maximovna, a 74-year-old grandmother, found this out the hard way when she called an ambulance complaining of chest pains. "What do you expect? It's time to die," the doctor told her. After she gave him 50 rubles, the doctor called her kitten and gave her some medicine, she said.

"There are some people in our profession who make their living by extortion," Danilin admits. "People judge every doctor they see by these [bad apples]. We cannot help that."

But if patients have complaints about the city ambulance service, the doctors have their complaints about the patients.

Both Danilin and Bogomolova agree they could work much more effectively if they were left to handle real emergency cases, and not calls from those who could not be bothered to go to the doctor.

"People prefer to dial 03 rather than to go to a polyclinic and spend several hours waiting in line to see their doctor," Danilin says.

Some patients force him to be tough with them, Danilin says, recalling one woman who used to call the ambulance every other day complaining of a heart problem. She kept demanding a certain pain killer, insisting it would make her feel better. In reality, Danilin says, she didn't need the drug - but she was addicted to it.

When the ambulance unit refused to give her the drug, the patient lodged numerous complaints with the City Health Department, convincing the authorities that she really needed the injections. Now, instructed by the city, 03 doctors have to visit her and provide her with the injection every time she calls.

Bogomolova recalls another case when an elderly woman called in a cardiology team. When the unit arrived she announced she was feeling fine but needed someone to change the light bulb in her kitchen.

Such trivial calls are common, Bogomolova says, adding that on some days the only form of medicine she practices is measuring blood pressure.

Ambulance doctors also spend a great deal of their time treating drunks - whether at home, or on the street.

"Often people see a drunk man sleeping on the street and call an ambulance for him and leave," says Bogomolova, whose unit covers the neighborhood around the Leningradsky, Yaroslavsky and Kazansky railway stations, a magnet for heavy drinkers.

Frequently the patient in question is off the street before the ambulance even gets there, Bogomolova says.

Their jobs were made even more difficult a few years ago, when the city health department issued a regulation ordering ambulance doctors to hospitalize everyone who falls ill on the street - including the city's homeless - regardless as to whether or not the patient requires further care.

The doctors are clearly unhappy with this order, which distracts them from the real emergencies. Just cleaning an ambulance after a homeless person has been treated takes over an hour, they say.

Bogomolova, for example, experienced a near miss not long ago after her unit was called in by a stranger who saw a homeless man passed out on the street. It turned out that the man had only been sleeping, but Bogomolova was required, nonetheless, to take the man to a nearby clinic.

"All the guy needed was a bath and some disinfectant, " Bogomolova recalls.

An hour later Bogomolova got another call - this time from a patient having a heart attack. The dispatcher directed her to take the critical patient to the same clinic that had received her previous passenger, unaware that the emergency unit had been closed down for disinfection after the homeless man had been treated. Bogomolova had no choice but to rush her unconscious patient to a different hospital, putting his life in greater danger.

Many of the doctors complain that these regulations slow down their response time - another common complaint among those who rely on the emergency service. The number of unnecessary calls, heavy traffic, and the limited number of vehicles and personnel all contribute to the city's notoriously slow service.

Theoretically, the average response time for an ambulance to arrive on the scene is 3 to 11.5 minutes, but Elkis says in reality it can take up to an hour. Part of the problem, doctors say, is that motorists do not grant emergency vehicles the right of way.

As a result, they are required to prioritize the calls on the busiest days. People who have been injured in car accidents, on the street, in public transport or at work are considered to be 03's top priority, demanding a 7 to 20 minute response time.

Those who find themselves in life-threatening circumstances in their homes should expect an ambulance to arrive within 20 to 35 minutes. People who suffer from chronic illnesses - such as heart disease - are lowest on the priority list. They can expect a doctor to arrive within 40 to 60 minutes of their call, a wait that could be deadly for someone whose symptoms, such as high blood pressure, develop into something more serious. Heart disease and strokes account for about a third of the calls to 03.

The number and nature of calls varies depending on the season and the weather. When the weather changes, a lot of people suffering from cardio-vascular diseases call in, while on weekends and public holidays fighting injuries are more common.

"For drunken brawls, Easter is probably the worst time of the year," Asriyan says. "People get drunk, argue and hurt each other. On these days we deal only with drunk patients for 24 hours."

About twenty percent of the 03 ambulances are Western-made vans specially equipped for cardiac, trauma, and toxicology patients. Doctors riding in these vehicles can handle most of the procedures carried out in city emergency rooms. But the vast majority of the city's fleet are aging, poorly stocked cars that are capable of offering only rudimentary first aid.

With the arrival of several private ambulance companies in Moscow, however, those who can afford to pay for the emergency service have the option of riding in style. A half dozen private ambulances now operate in Moscow, many of them employing doctors who have previous experience working with 03.

Some private services operate through insurance companies and offer first aid to their clients exclusively, while others respond to all calls and charge patients for transportation and consultation. Fees for their services start at 800 rubles ($33).

Private services are generally more efficient since they receive fewer calls and can dedicate more time to each patient. Like the city-run ambulance, all private services have access to most Moscow medical facilities and can arrange for patients to be hospitalized in elite clinics, such as the Central Clinical hospital, which is frequented by President Boris Yeltsin.

The caseload of the private services is a sharp contrast to 03. Generally those who have been injured in a drunken fight cannot afford to call a private ambulance. They also see fewer accident cases. The bulk of their patients suffer from food poisoning, heart attacks, strokes and epilepsy. These services can also arrange for transfers from one clinic to another.

Doctors working for the private ambulance services claim that their job differs little from their days on 03, but better equipment and a wider variety of medicines enable them to feel more confident when treating a patient. Furthermore, most private ambulance doctors are paid twice as much as their 03 colleagues - a perk that draws many to the job.

Gennady Gorbachev - who worked on an intensive care unit before joining the medical staff of Lechebny Tsentr, a clinic that runs its own private ambulance service - is skeptical about the level of care the city ambulance is able to provide.

"Doctors at 03 are underpaid, angry and disillusioned," Gorbachev says.


Moscow's Private Ambulance Services

The oldest private 24-hour first aid service in town, Medexpress (tel. 401-5470), has been operating in Moscow for six years. The company has four stations throughout the city and at least a dozen Ford and Mercedes ambulance vehicles with diagnostic and life support equipment. Medexpress charges 850 rubles (about $34) per hour, and the clock starts running the minute the team departs the station on a call. Ambulance teams can also travel outside Moscow.

Another service, Medep (tel. 143-6343 or 143-1798), is the only private service in town that has a specialized pediatric first aid team. It charges 850 rubles per hour and offers hospitalization in any of the city's clinics.

A similar service operates at Lechebny Tsentr clinic (tel. 257-2371 or 257-2532). One ambulance visit costs 1,000 rubles.

Last year, the Renaissance insurance company and the Centre of Family Medicine set up an ambulance service (tel. 956-9911 or 956-9955) for those who live along the Rublyovo-Uspenskoye Shosse, just west of the city. This region is popular among wealthy Russians and expats, especially for those seeking summer dachas. Response time for the ambulance is within 15 minutes.

With an $80 annual membership, clients may call the ambulance service as often as is necessary over the course of the year. Hospitalization fees are not included, running $290 per admittance to a reputable Moscow clinic. (As a rule, municipal ambulances take out-of-town patients to the nearest hospital, regardless of whether or not it is well-equipped to handle the emergency.)

American Medical Center, or AMC (tel. 956-3366), hires ambulances from Russian first aid companies Meditsina and Medexpress, and an AMC doctor accompanies the emergency team when necessary. When a doctor from the clinic does not travel with the emergency team, he stays in touch via telephone.

Under life threatening circumstances, the AMC hospitalizes it's patients in one of four Moscow clinics with which it has a special arrangement. AMC charges $300 for the first hour of the ambulance team's work and $175 for each subsequent hour of emergency medical care.

The International Medical Clinic, or IMC, also has an ambulance service (tel. 280-7177), but the clinic did not wish to publish its prices

The European Medical Center (tel. 956-7999) does not have an emergency ambulance service, but its doctors do make house calls. One visit costs $160 to $200, depending on the distance traveled.