EMS spends an extraordinary amount of time measuring what happens after someone calls 911.
Response time. Chute time. Scene time. 12-lead acquisition. Aspirin administration. STEMI activation. Transport time. We have enough clocks, dashboards and KPIs to decorate a reasonably large Christmas tree.
But what about the patient who never calls us?
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A 2026 study published in Scientific Reports, “Perceptions and emergency medical service use for acute myocardial infarction among community-dwelling older adults,” examined how older adults perceive acute myocardial infarction (AMI), how they view EMS, and what influences whether they would actually use EMS during a suspected heart attack.
The study was conducted in Thailand, so we shouldn’t directly apply its percentages to U.S. communities. But the human behavior it describes will sound remarkably familiar to anyone who has spent time in an ambulance.
Here are five things EMS leaders should take away from it.
1. Knowing to call EMS and actually calling EMS are different things
Participants generally understood that heart attacks require rapid medical treatment and recognized the potential benefit of EMS. Great. Mission accomplished, right?
Not exactly.
While 61.7% indicated they would call EMS during a suspected AMI event, only 48.9% said calling EMS would be their first action when confronted with symptoms. There’s apparently an entire decision tree hiding between “something is wrong” and “call 911.”
People may wait, call a family member, try a home remedy, ask the neighbor or decide to drive themselves.
For decades, our public education message has essentially been: Recognize the symptoms. Call 911. This study suggests we need to better understand what happens between those two steps — and why patients who know EMS is available still choose something else.
2. Our biggest competitor may be the car in the driveway
Some study participants preferred private transportation because they believed they could reach the hospital faster themselves. Others were uncertain about ambulance availability or how long EMS would take.
The researchers identified three general groups: people who would use EMS, people who would not, and people whose decision depended on the circumstances. That last group deserves our attention.
Patients are essentially conducting their own emergency medical dispatch protocol at the kitchen table, unfortunately, without ProQA. This means public perceptions about EMS response times may affect more than satisfaction scores. They may affect whether people call us at all.
Our community education should reinforce an important distinction: An ambulance isn’t simply transportation to medical care. It brings medical care to the patient. Assessment, ECG acquisition, monitoring, treatment, resuscitation capability, destination decisions and hospital notification can begin before the patient reaches the ED.
The real question isn’t necessarily “Which vehicle gets me to the hospital fastest?” It’s “How quickly can meaningful medical care begin?”
3. Heart attacks don’t always read the textbook
Older adults can experience atypical AMI symptoms, including fatigue, shortness of breath and abdominal discomfort, symptoms patients may not immediately associate with a heart attack. Misinterpreting these symptoms can delay care.
Study participants described trying self-management strategies before seeking medical attention, including rest, massage, inhalers and other remedies. EMS clinicians everywhere are now nodding.
We’ve all met the patient whose symptoms started three hours ago but who wanted to “see if it would go away.” Spoiler alert: if there’s now a paramedic in your living room holding a 12-lead cable, it apparently didn’t.
This represents an opportunity for EMS community education, particularly with older adults and caregivers. Our message needs to extend beyond “chest pain equals heart attack.” Sometimes it’s weakness. Sometimes it’s nausea. Sometimes it’s shortness of breath. Sometimes it’s simply, “Something isn’t right.”
4. People still have some interesting ideas about ambulances
Although participants generally demonstrated a reasonable understanding of EMS, misconceptions persisted. About 25.6% believed ambulance care carried a high risk of infection, 17.3% thought ambulances were only for accident patients, and 16.5% believed ambulance service required payment.
Even more striking, 94% believed they should get to a hospital immediately rather than wait for an ambulance during an emergency — a perception that could influence their decision to use private transportation. Additionally, 78.9% believed ambulances were relatively scarce and therefore they should be reserved for more seriously ill patients.
In other words, patients may be self-rationing EMS. “I don’t want to bother the ambulance.” “Someone else might need it more.” “My spouse can drive me.”
That sounds reasonable until the spouse is driving 83 mph toward the ED while simultaneously trying to determine whether the passenger is still breathing.
EMS agencies routinely survey patients after they use our service. Maybe we should occasionally survey the people who haven’t. Do residents understand when to call? What paramedics can do? What an ambulance might cost? How destination decisions are made? Whether calling EMS actually delays their arrival at definitive care?
We may be surprised by the answers.
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5. Patient experience today may influence the next 911 call
The study also highlights the importance of previous experience with EMS. Some participants with prior AMI or EMS experience described greater confidence in EMS personnel, equipment and capabilities.
That suggests something worth considering:
Patient experience isn’t merely a customer-service metric. It may influence future healthcare behavior. Every EMS encounter teaches patients and families something about us.
Were we compassionate? Did we explain what was happening? Did the patient feel safe? Did the family understand why EMS care mattered? Did the crew inspire confidence?
Today’s patient may be tomorrow’s spouse, caregiver or bystander deciding whether to call 911. A positive EMS experience could influence how quickly that decision gets made.
The metric we may be missing
This study has important limitations. Participants were largely describing what they thought they would do during a hypothetical AMI rather than what they actually did during a real emergency. The researchers also found that many associations between perceptions and intended EMS use were relatively weak.
But the study raises an important question. EMS measures response times, clinical interventions, outcomes, patient satisfaction and dozens of other indicators.
Perhaps we should also be measuring something else: Does our community understand and trust its EMS system?
Because the most sophisticated EMS system in America can’t perform a 12-lead ECG on a patient who never calls.
EMS leaders should consider adding community awareness, confidence in EMS, and understanding of appropriate EMS utilization to their public education and performance measurement strategies.
We can have exceptional paramedics, phenomenal protocols, whole blood, ultrasound and enough technology in the ambulance to make NASA mildly jealous. But none of it matters if the ambulance stays parked at the station.
Perhaps one of the next frontiers in EMS performance isn’t simply getting to patients faster. It’s making sure patients understand why they should call us in the first place.
