LET’S IMAGINE what would have happened if, on the afternoon of Jan. 25, D.C. firefighters at Engine 26 had been alerted by passersby not to a man who had collapsed outside their station but to a trash fire across the street. Our guess, and that of public safety officials we queried, is that there would have been an immediate, unhesitating effort to douse the flames.

The lack of response when a 77-year-old man needed help speaks to one of the recurring problems in the District’s Department of Fire and Emergency Medical Services. Calls for medical help now make up more than 80 percent of calls to the department, yet there are still firefighters who see their role as battling blazes, not tending to the sick.

Medric Cecil Mills Jr. died from a heart attack following indifferent treatment by rescue workers and the bungled handling of a 911 call. What makes his case doubly distressing is the familiarity of the shortcoming it illuminates. This is not a new story.

A 2005 examination of emergency services in the country by USA Today depicted the District as a poster child of dysfunction, marked by infighting between fire and ambulance crews. That report, which chronicled the needless death of a 21-year-old student who got delayed treatment, came well before the notorious events that surrounded the 2006 death of former New York Times reporter David Rosenbaum.

In that case, emergency workers assumed Mr. Rosenbaum was drunk, rather than the victim of a vicious beating, and an ambulance bypassed a close-by hospital so a driver could take care of a personal errand. The resulting uproar resulted in some reforms. But it’s clear from Mr. Mills’s case and the department’s continual turmoil — ambulances out of service, firefighters calling in sick en masse, lingering racial tensions, turf fights between different unions — that more change is needed. The answer isn’t as simple, as some D.C. Council members have advocated, as booting out the chief. It’s ironic that some of the same people calling for the removal of Fire Chief Kenneth B. Ellerbe blocked him from changing how the department is staffed and its resources are deployed.

The succession of fire chiefs and controversies suggests that the problems are more deep-seated than who is at the top. Mr. Ellerbe’s effectiveness may be so eroded at this point that a change of leadership may be needed. But bolder action is required if there is ever to be real change in this long-troubled department. It was probably a mistake after the Rosenbaum death not to create and empower a separate agency with full-time paramedics and emergency medical technicians who want to provide patient care, instead of seeing it as something they are forced to do. Boston, with its separate EMS and fire operations, should serve as a model of what is both possible and desirable.

It is time to take another look at this issue and adopt remedies that do more than offer lip service to safeguarding public safety.