The council hearing already had been tense, coming barely a week after the latest ambulance tragedy, in which D.C. medics failed to find their way to a dying man for nearly 40 minutes.

After listening with increasing disbelief, D.C. Council member Jim Nathanson (D-Ward 3) suddenly confronted Fire Chief Theodore R. Coleman, asking him to explain remarks made minutes earlier -- that ambulance drivers receive only two hours' training in city geography.

Coleman said the training policy was sufficient. The ambulance drivers, he told council members, also learn directions by "being out on the streets quite a bit."

Outraged, Nathanson began a 10-minute debate with Coleman that ended with one question: "Chief, do you really think this kind of training is enough?"

As the council members watched silently, Coleman remained composed, but reversed himself abruptly. "Now," he said, "I don't believe so."

That brief confrontation illustrates one of the chief problems that has troubled the city's ambulance service since Coleman became fire chief in 1982, sources close to the ambulance service said last week. They said Coleman consistently has resisted any comprehensive response to the continuing ambulance troubles, instead adopting piecemeal changes only in the face of crisis and outside pressure.

As public demand for change increased in the wake of reports that nine people died after ambulances were slow to arrive, Coleman limited the authority of his ambulance service directors and became consumed with anger toward his critics in the medical community who demanded reform, sources said.

Coleman's apparent reliance on crisis-atmosphere decisions and his reluctance to pursue lengthy and rigorous planning contributed to Mayor Marion Barry's decision this week to oust the fire chief as supervisor of the ambulance service, the sources said.

On Friday, Barry announced that City Administrator Carol B. Thompson had been given control of the service, and that ambulance director John M. Cavenagh, with whom Coleman has reportedly clashed, now reports to her.

Barry's removal of Coleman, who will continue to serve as fire chief, came after three weeks of harsh criticism of the ambulance service. Less than two weeks ago, Barry's advisory committee on emergency medical services voted that it had "no confidence" in Coleman's ability to manage the ambulance bureau. One day earlier, the city's Paramedic Review Board, which certifies paramedics, threatened to resign, citing "grave concerns" about a lack of fire department cooperation. Three D.C. Council members also asked that Coleman, 61, resign or be removed from supervising ambulances.

"What we've been lacking is an overall commitment to change," one high-ranking fire department official said last week. "For too long, it's just been, 'Okay, how can we survive this crisis?' "

Barry would not allow Coleman to speak at Friday's news conference, and Coleman declined to answer reporters' questions as he left the District Building. He also has refused all requests to be interviewed.

A 35-year department veteran, Coleman has overseen the city's ambulance service since he was named fire chief in 1982, but he encountered little criticism for its performance until July 1986, when a city task force report issued an across-the-board condemnation of the service's training, equipment and communications system. The task force recommended sweeping policy and procedure changes.

Although Coleman swiftly dismissed the report as largely inaccurate, its findings were underscored in a grisly fashion: From September 1986 through Jan. 15, nine District residents died after ambulances were slow to arrive, and there were numerous reports of sloppy dispatching and ambulances getting lost.

City officials have established no link between the deaths and the ambulance delays.

Sources said that even as other city officials have embraced the report as a blueprint to improve the service, Coleman -- whom sources portray as extraordinarily sensitive to criticism -- continued to resent its negative description of him and the fire department.

Most task force members have said that only "cosmetic changes" have been made in the ambulance service since the report, and attribute the lack of progress, in part, to Coleman's bitterness.

"When they were trying to go ahead with the report, it was like, 'Just keep Coleman out of it,' " a high-ranking fire department official recalled. "Everyone knew how he felt about that report."

Instead of seeking a general overhaul of the ambulance system, one city official said, Coleman's management was "reactive and tentative."

The official and other sources cited Coleman's response to the ambulance service's most highly publicized problem: delays in getting to the scene.

Amid recurring reports of lost or late ambulances in the spring, Coleman's response was to order a deputy fire chief to hurriedly purchase dozens of $8.95 street maps and distribute them to ambulance crews.

The maps, however, had flaws, including the omission of some small streets from its indexes. Last month, after ambulance drivers became confused reading the maps and took 40 minutes to reach the home of a Northeast man who later died, Coleman issued another order: Crews should never leave a station, he said, "without knowing exactly where they were going." Coleman also instructed fire station captains to compile lists of tucked-away streets in their jurisdictions for ambulance crews.

Never during that period, sources said, did Coleman or other fire officials order increased training to ensure that ambulance drivers knew city streets.

In another case, Coleman recently ordered, without ambulance director Cavenagh's consent, that one member of each of the city's 21 ambulance crews remain seated at fire station watch desks if not responding to an emergency call. The reason, said Capt. Theodore Holmes, a fire department spokesman, was that "we were getting beaten over the head with cases of ambulance crews not being immediately available because they were asleep somewhere, or out washing their cars or quickly going out to get gas."

The fire department has made some long-term improvements. It is planning to install a state-of-the-art computer tracking system to aid dispatchers, and has made a majority of its firefighters become certified in cardiopulmonary resuscitation in the past 18 months.

But although some medical and fire department officials interviewed last week conceded that Coleman's reactions had merit, they emphasized that more significant issues, such as workers' training and morale, have been inadequately addressed.

"We never seem to escape crisis-management reactions," said one fire department official.

Sources said efforts to reform the ambulance service also have been marked by strained relations between Coleman and his ambulance supervisors.

Since he became fire chief, Coleman has had nine ambulance directors serve under him. In 1987, three temporary directors were appointed in less than one month. Former director McEldon Fleming quit after three weeks, citing lack of support from Coleman. Sources said that Fleming was not able to choose his staff.

The inability to choose his own staff also has frustrated Cavenagh, the service's first civilian director, who was selected in the fall after a five-month national search. Like others before him, he reportedly struggled to gain Coleman's cooperation in improving the service. Coleman and Cavenagh had publicly denied that a rift exists between them, but at a news conference last week, Cavenagh acknowledged that he had wanted to select his own assistants but had not been allowed to do so.

In addition, the ambulance service's lack of medical supervision has caused friction between Cavenagh and Coleman.

The service has not had a full-time medical director since 1986. The position is needed, medical officials say, to review ambulance response, ensure that training meets national standards and act as a liaison with the medical community.

Coleman told council members recently that "we just don't seem to get any takers" for the medical director's position, but did not elaborate on his remarks. However, sources within the medical community said potential candidates have been discouraged by the strife surrounding the ambulance service.

Fire department and medical sources interviewed this week said many of Coleman's problems stem from his professional background, which is exclusively in fire protection.

"You can't bring a man up from the fire side, and expect him to manage an ambulance service," said one official who has worked with Coleman often. "They are much more different than they are similar."

Even at the height of the crisis, sources said, Coleman gave the ambulance service secondary status. And even in his direction of the firefighters, they said, he frequently seemed preoccupied with matters of style rather than substance.

In the past year, Coleman has ordered fire trucks to be repainted and placed bronze plaques bearing his name and title on most of the city's fire stations.

At an early January meeting of high-ranking department officials, sources said, Coleman referred to the department's 1988 Christmas party on the agenda, and said he wanted it to be "much bigger and much nicer."

Coleman also has focused much of his attention on the International Association of Fire Chiefs convention in Washington in August. He will be the first black fire chief to preside over the convention, and fire department and city officials have said that it is likely he will retire soon after its completion.

Even Coleman's harshest critics, however, agreed that his removal Friday will not by itself solve ambulance service problems.

"The fact of the matter is that the whole system is diseased, and things like the Paramedic Review Board almost quitting are symptoms of that disease," said a medical official who has worked on the city's ambulance task force. "Even with Chief Coleman out of it, there's still plenty to worry about. The feeling is, 'Now, we've got a chance.' But the bottom line is people will continue to die because the ambulance system, as it stands, simply cannot survive."

Controversy has chased the city's ambulance service since 1981, when then ambulance director Ramon Granados resigned and warned that the District government was "ignoring dangerously slow response times."

According to task force reports, the ambulance service is among the busiest -- but slowest -- in the country. It received 142,000 calls for emergency assistance in 1987, though 35 percent of those did not require hospital transport.

Cavenagh, who has 15 years of experience in emergency medicine and is well-regarded by the city's medical community, has said that the ambulance service is critically short of paramedics, and there has not been any paramedic training since May. Faced with a shrinking pool of qualified applicants, Barry reiterated Friday that he will ask the D.C. Council to lift the city's residency requirement to hire paramedics.

Also, sources said the ambulance service must strengthen instruction for emergency dispatchers, who do not receive formal training courses, follow-up evaluations or probationary periods. "We often have people who come here without emergency expertise and are put into this high-pressure situation without consistent training," said one 911 dispatcher. "It's like Russian roulette. Some make it, some don't."

City ambulance workers said in interviews last week that continued negative publicity about ambulance delays has lowered morale.

"The people on the street are definitely becoming more abusive," said one driver. "It's as if they almost expect us to be incompetent upon arrival."

Medical officials in the city reacted cautiously to Barry's reorganization plan Friday, applauding the mayor's concern but warning that serious ambulance reform is long overdue.

"Chief Coleman runs a good fire service, but we've always questioned his stewardship of the ambulance service," said Dr. Howard Champion, director of the Washington Hospital Center's MedStar trauma unit. "Something had to be done, and I now hope that she {Thompson} will follow through on the issues that need to be addressed -- and do so immediately."