The District of Columbia Fire Department's Ambulance Division has once again been criticized for delays in providing service to a critically ill District resident. A special panel has been appointed by Mayor Barry to investigate the incident. Unfortunately, this sequence of events has become all too familiar to the citizens of the District.

Since 1986 there have been nine reported incidents in which people died while ambulances were delayed or never reached the victim. There have been an equal number of investigations. Repeated promises by District officials of major improvements have failed to materialize. The medical community is frustrated and angry, and good paramedics are dispirited and leaving their jobs.

Placing responsibility for these delays on the personnel on the front lines begs the question. These incidents are not isolated events; rather, each represents a symptom of a system that is in disarray, lacking effective leadership and direction. In 1986, in response to pressure from members of the medical community, a task force was appointed to study the ambulance division and to make recommendations for improvement. Two years later, too little has been done to implement those recommendations, and the District of Columbia's ambulance service is a national embarrassment. The prevailing opinion among the rank-and-file is that the "right" person has not yet died, a sad and bitter commentary on the lack of constructive action from the Fire Department.

In 1977, following the cardiac arrest and resuscitation of Judge John Sirica, the District enacted legislation permitting paramedics to perform Advanced Life Support in the field. With the addition of paramedics, what had been a transport and basic life support system became a "physician extender" advanced life support system of care. The D.C. Ambulance Service became part of the medical system.

Medical systems that deliver effective service and quality patient care have three essential elements in place: medical control protocols, quality assurance audits to assess patient care and physician input into the operations of the system so that quality care can be attained and sustained. There is no substitute in an emergency medical system for guidance and supervision from physicians. This medical direction is the critical element missing from the District of Columbia's Ambulance Service.

Since Fire Chief Theodore Coleman took office in 1982, there have been nine different directors of the ambulance service, none of them physicians. Attempts to recruit a qualified medical director have been hampered by the decision to subordinate the position to the fire chief, an arrangement that has proven ineffective.

The D.C. Ambulance Service must have medical leadership and supervision independent of the fire chief. This goal could be accomplished in a variety of ways. The first option is to place the medical director in the office of the commissioner of public health, an alternative long favored by the medical community.

A second alternative would provide medical control by a contractual arrangement with a physician. This would allow the ambulance service to remain in the Fire Department, with patient care monitored and supervised externally.

The third alternative, one that has worked well in other cities, would make the ambulance division a separate public service with leadership and budget appropriations independent of the Fire Department. Chief Coleman's long track record of ignoring major problems with the ambulance service makes this last alternative increasingly attractive.

Time is running out for the District of Columbia. Because the Fire Department has shown itself incapable of responding to the emergency medical needs of its citizens, several organizations in the city are investigating the option of developing their own private emergency ambulance systems. This trend is especially disturbing, as it raises the specter of ambulances competing for patients, creating greater confusion and lack of coordination.

The District has shown itself to be a leader in urban renewal and in developing innovative programs for its public school system. Such skill and leadership must now be applied to the ambulance service. The message to the residents of this city must be that the life of each citizen is equally important, and continued deficiencies and delays will not be tolerated. Solving the problems of the ambulance service is not only a matter of civic pride, it's a matter of life and death. -- Mary Joy Drass, M.D. is medical director of Medstar, the trauma unit at the Washington Hospital Center, and a resident of the District.