MOSCOW -- Alexander Padin lay face down on a neighbor's living-room floor, bleeding heavily from a deep wound in his back, and all the frustrations of working in Moscow's crumbling ambulance service seemed to accumulate before a weary Dr. Igor Burykin.
The electricity had been knocked out, so Dr. Burykin was working by flashlight. But the flashlights faded quickly and went dead, leaving only candles flickering on a bureau beside him. Meanwhile, someone had to spend precious minutes rummaging the ambulance for bandages, while Mr. Padin kept bleeding.
Down on the street, the six rickety but working ambulances from Emergency Aid Station No. 2 were lined up, summoned to the fire that was engulfing Mr. Padin's apartment building. It was 3 a.m. last Thursday morning. Seven other ambulances were idle at the station, broken down and useless.
A disaster response team was also standing by, watching as the flames sprouted from the roof and sent burning window frames cascading into the snowbanks below.
"Look at them," Dr. Burykin said, his dark eyes alight with anger and frustration. "They're doing nothing. That's because there's nothing they can do. They have no equipment. They have nothing. What's the use?"
The 35-year-old Dr. Burykin was hardly alone in his despair. Moscow's ambulance service is beyond the point of crisis, well past the verge of breakdown. It has become one of the city's most visible victims of Russia's economic and administrative collapse.
On average, 233 of the city's 589 emergency ambulances are out of service every day. Those that are working are often called upon to cover the gaps in the city's nonemergency system, where one day last week 100 out of 145 ambulances had broken down.
Response time in the city of 10 million is measured in hours, not minutes.
"You can wait two, four, six hours before the ambulance comes for you -- if you're still alive, that is," Dr. Leon Akopov said.
Dr. Akopov is head of a strike committee that plans to begin a limited work action March 1. The committee is calling on the 7,500 medical workers in the ambulance service to withhold paperwork on each case, and, in a dramatic gesture, to refuse to pick up the 40 or so bodies found on the streets of Moscow every day, dead mostly from drinking or freezing, or both.
The strike committee is asking for higher pay, but their primary demand is to put working ambulances back on the streets and to stock them with proper equipment.
For now, though, Moscow is served by a system seemingly held together, if at all, by patches and make-do. The doctors and medical assistants swing from moods of jaded cynicism to bouts of inspired hard work -- and life-saving improvisation.
Mr. Padin's treatment was one example of that. Though the bandages were mislaid and the flashlights failed, he was stabilized finally and taken off to a hospital, where he should recover.
When Dr. Burykin found him, he was lying stripped to his underwear on the floor of a small apartment, where he had been carried after leaping from his fourth-floor window. He had a deep wound in his back and had probably broken an arm as well. He was shivering uncontrollably.
He needed help on the spot. While children cried all around and firefighters trooped in and out, Dr. Burykin set to work. But even ++ after the bandages were found, it was slow going in the dim candlelight, and Mr. Padin was slipping deeper into shock.
Finally, someone scrounged up some miners' helmets, with lamps on them. Volunteers donned the helmets and knelt in a circle around Mr. Padin, and Dr. Burykin finished the job.
Four others were injured in that fire, straining Emergency Aid Station No. 2's resources to the utmost.
It was over in little more than an hour.
When the ambulances scattered to various hospitals, they left behind two people, an elderly woman and a young child, who had burned to death. The morgue could send vans out for them later.
It was the single dramatic moment of a day that had started for most of the crews more than 19 hours earlier, on Wednesday at 9 a.m. It had been a day, in fact, like most others: a few genuine emergencies, and an endless succession of routine calls.
Serious injuries, especially gunshot wounds, are on the rise in Moscow, but so are all kinds of other demands on the ambulance service, for both real and imagined emergencies.
Some people, alone, elderly, are really looking for a cheering word and a little company. Others, dismayed at the prices clinics charge for medicine, know that Emergency Aid doctors distribute the same medicine free. Still others know they need to see a doctor but have no way of getting around the city.
Sometimes somebody sees a drunk passed out on the sidewalk. The ambulance will come for him, too, but take him to a police station instead of a hospital.
If he has lice, that means putting the vehicle and crew out of commission for up to eight hours, for disinfection.
Each ambulance has a driver, a doctor and a medical assistant, who work 24-hour shifts every fourth day. The doctors earn a base pay of 280,000 rubles a month (about $178), but most work overtime. In a hangover from the Communist system, drivers earn slightly more than the doctors.
Dispatchers try to sift through the calls so they can give priority to the serious ones (unfortunately missing a few).
When the call came for the fire at Mr. Padin's apartment house, for instance, the ambulances responded immediately and were there within minutes, even though at that point they were running about three hours behind on routine calls.
Dr. Vladimir Bezborodov has worked for the ambulance service off and on since 1964.
He is a patient, quiet, unfailingly sympathetic practitioner. He likes emergency work because there's always some new problem to be tackled.
Wednesday began for him with a call from a 44-year-old woman in a fifth-floor walk-up who was suffering from excruciating pain in her lower back and right thigh.
Dr. Bezborodov guessed that it was a pinched nerve. He had his assistant, Svetlana Pravoslavnova, administer an injection of pain-killers -- which he doesn't usually like to do because it masks the problem -- and then they took her to the Botkin Hospital for a more thorough exam.
They stopped so that Ms. Pravoslavnova could pick up a few groceries, and then went to the next call: an 82-year-old woman who thought she was having a heart attack.
Though there wasn't really anything wrong with her, Dr. Bezborodov listened patiently to her complaints, asked her about her appetite, listened to her heart, talked to her some more.
The woman's daughter, smiling shyly, gave him some chocolates.
"They rely on us to calm them down," he said afterward. "It's part of the job."
Then it was on to a 31-year-old railroad engineer, who lives with his wife and baby daughter in one room of a communal apartment.
His regular doctor suspected tuberculosis, but knew that the engineer wouldn't be given a serious examination at a hospital unless he came by ambulance.
Dr. Bezborodov obliged. The visit took four minutes. The trip to the hospital took half an hour.
On the way Dr. Bezborodov, 58, confided that the excitement of emergency work used to get to him, until one day he realized he was drinking an entire bottle of vodka after every shift.
He swore off drinking after that, and kept working.
His day wore on in the same fashion -- part social work, part taxi service, part medicine; endless forms, a certain lack of hurry, and a lot of talk back at the station about Russia's humiliating 5-0 loss to the Finnish hockey team in the Olympics -- until 3 a.m., when routine was forgotten and everyone raced to the fire.
Station No. 2, one of 45 in Moscow, gets about 150 calls a day. It is supposed to have 22 ambulance crews on duty in the daytime hours and 13 at night. Wednesday morning, 10 ambulances were working.
"And how do I know how many will break down today?" demanded the station's energetic 80-year-old chief, Dr. Lev Arshinov. (Actually, only one did.)
The service uses Rafik vans, made in Latvia, which are designed to last four years. Two years ago Latvia became an independent nation and began demanding hard currency for the Rafiks. Moscow stopped buying them.
That, more than anything, is what has led to the breakdown in service. The city administration contends, however, that it is getting a grip on the problems, that new ambulances will start arriving soon and that the threatened work action has more to do with internal politics than concern for people's welfare.
"The city promises a lot, but there's nothing. It will never happen," said Dr. Arshinov. "This isn't work. It's self-sacrifice. Sometimes when we're down to only four ambulances, we might be 13, 15 hours late to a call. What kind of emergency aid is that?"