The emergency call came in, and Dave Milsted and Bruce Wallace climbed into the ambulance and raced through traffic to a Cherry Hill apartment building.
They arrived to find an elderly woman with a history of diabetes struggling to breathe. Milsted, 47, a paramedic who has been in the business since he was 16, should have started checking her blood sugar.
But doing so would have violated state rules that prohibit anyone considered a first-responder from doing anything beyond what is defined as basic life support, regardless of certification. The question of whether that is the most efficient way to provide emergency care is difficult to answer because of the sparse data collected under the state's regulatory system, which has changed little since the 1960s.
Last Tuesday afternoon, Milsted waited for a paramedic team to arrive, a team working out of a hospital and therefore legally allowed to take a blood sugar level or hook up an IV or just give someone with chest pain an aspirin. These are all things Milsted does every couple of weeks when he works an advanced life-support shift out of the same hospital.
"It's frustrating, to know I can do this," he muttered later.
The paramedic team rolled up just as the patient was wheeled outside. Milsted and Wallace had to repeat the clinical history they had already assembled, and then there were four people attending to the woman, who would be given an IV and shipped to a hospital just across the road.
"There's just a bit of overkill," Wallace said sarcastically. "Most of what they just did, we already did upstairs."
That analysis is open to debate.
What might seem a routine case one moment could suddenly become much more serious, says Scott Kasper, director of emergency services for Virtua Health, which runs advanced life-support teams in Camden and Burlington Counties.
"The unknowns force us to have what a casual observer might see as overkill in the system," he said.
But as anyone involved in emergency-medical services in New Jersey will readily admit, there's no way to tell how effectively the system is working. Response times, quality of care, and other key statistics used in almost every other part of the country to track EMS are often not reported here, said Assistant Health Commissioner David Gruber.
"We are approaching crisis," he said. "You're seeing a system that hasn't changed much in tens of years, since it was created. Do we have enough trucks out there? We don't have the metrics to know whether we do or not."
That could soon change.
After years of stops and starts, legislation has been introduced by State Senate President Stephen Sweeney (D., Gloucester), State Sen. Joseph Vitale (D., Middlesex), and Assemblyman Herb Conaway Jr. (D., Burlington) that would require EMS providers to collect and report data and create uniform standards for training, all overseen with a far greater degree of state authority than currently exists.
"We have a less well-organized system than we should. It costs us more money than it should," said Conaway, a practicing physician in Willingboro. "Hopefully it will put us on the path to rightsizing our EMS delivery system."
Among the jumble of agencies that form New Jersey's EMS landscape - from volunteer and professional emergency medical technicians in private and public sectors to advanced paramedic teams run by hospitals - there is overwhelming agreement the time for change has come.
But what kind of change?
Should volunteer EMTs, who work day jobs and have limited free time, be held to the same training standards as the career EMTs who work out of firehouses? Should response-time standards be universal, or vary depending on whether the call is in an urban or a rural area?
One big question is what to do about paramedic units, which operate out of a smaller number of stations and thus typically travel farther to emergency scenes, slowing their response times.
While no one sees the system changing to one like Philadelphia's, where a paramedic is assigned to every ambulance and fire truck and is always among the first on the scene, there is movement toward expanding the role of EMTs to include procedures such as inserting breathing tubes, checking blood-sugar levels, and administering basic drugs.
Cherry Hill EMS Chief Randy McCargar estimated that making that change would cut the need for advanced life-support teams by 85 percent.
That could cut in half a bill for someone like the woman attended to by Milsted and Wallace, McCargar said.
"We have multiple units responding to the same emergency. The expenses, once we get paid and the paramedics get paid, are pretty significant," he said.
Kasper questioned the efficiencies the rule change would create. He also argued that the current division of labor means paramedics work only on more severe cases, instead of splinting broken limbs or administering oxygen to a hyperventilating patient.
"If you have a relatively large number of paramedics handling all those cases, those critical lifesaving skills are not being maintained to the same level," Kasper said.
If legislation passes to compile EMS data, perhaps the question of the most efficient way to provide emergency-medical care could begin to be answered.
But for those on the street, the issue of the greater good fades when presented with a patient who could live or die depending on the actions they take.
A couple of years ago, Milsted was called to the scene of a patient in cardiac arrest. The paramedics did not show up immediately, and Milsted calculated it would be faster to take the patient straight to the hospital.
During the lag time, he was unable to administer cardiac drugs or a breathing tube, as he would have had he worked out of a hospital that day. The patient was pronounced dead at the hospital.
"Patients die," he said. "Would it have meant a difference in the outcome if the paramedics were there? I can't say. Even if the paramedics are there, many times there is not a positive outcome. You just don't know."