The following is part two in a series; read part one, here.
*
I was having one of those nights that, if it doesn’t break the heart, roughs it up. My partner for the shift, and the ambulance’s driver, was Talia. We had been called to the house of a patient with multiple sclerosis who had fallen face-forward out of her wheelchair. From the prone position in which she’d landed, the patient had alerted 911 through her medical alarm bracelet.
The home was a row house in a complex of identical structures. We parked the ambulance by the curb and approached in the wash of red-and-white ambulance lights. The call had not been dispatched as a “person under investigation” for Covid-19, but the county field guidance recommended enhanced personal protective equipment regardless. Our patient might have a mild course of the disease or even be asymptomatic. I was wearing an N95 mask, eye goggles, a face shield, an anesthesiologist’s-style hat, gloves, and my “Smurf suit,” a blue-and-reflective-yellow boots-pants-and-jacket ensemble that fit over my uniform and provided contact protection.
Gaining entry into a home from which someone has called 911 is not always as straightforward as one might expect. Sometimes people leave their doors open for first responders, while they go elsewhere, typically to attend to the patient. When that happens, I enter hesitantly. I always have to quiet a sensation of concern that arises when I walk into someone else’s home and find an empty room. I’m not breaking in—they have invited me, asked for my help—but my awareness of the social prohibition of being in someone’s living room when they don’t yet know that I’m there is nonetheless strong. I call out, “911! EMT’s responding to 911! Hello?”
By contrast, some people don’t leave their doors open, and don’t answer them when you knock, either. Standing outside, banging on the door and shouting, “911! Did someone call 911?,” I remind myself to take a deep breath. The act of pounding on a door can rile me up, which isn’t optimal: what the patients will need from me—and what I require myself—is calm. Also, if someone has called 911 and is now not answering, their situation could have escalated. They might be non-responsive. Their need for assistance could be even more urgent. In that case, we force entry using the halligan pry tool that we keep in the ambulance. If my partner and I cannot force the door open, I radio dispatch to send me an engine. The firefighters can break down the door.
Then, of course, there are the instances when EMTs have been shot through closed front doors. As a result, we are trained to stand on either side of the doorjamb when we knock.
This case did not fall into any of those scenarios. The front door handle had a lock box around it. Dispatch provided us with the code (which had been given to them by the patient’s medical alert provider). The lock box contained the key to the house.
Once inside, we were engulfed in a blaze of noise. A television in the living room blared at top volume. A riot of possessions crowded the space, suggesting hoarding. I didn’t see how anyone could navigate the area in a wheelchair.
“I’ve been here before,” Talia remarked.
We saw no one and started calling out. Over the decibel tsunami, we discerned the patient’s answer. We followed the cry into her bedroom, where another television blasted an even more deafening assault.
The room was a landscape of obstacles. The bed was buried under piles of things—electronics, purses, compression wrappings in plastic bags, decorative pillows, crocheted throws. A bedside commode was full of feces. The floor was covered with heaps of clothing.
Frightened of contracting the virus, and despairing of being separated from family, no one wants to go to the hospital.We were at a loss to locate the remote control to lower the volume, and the patient’s wheelchair blocked our access to the television. It also obstructed our ability to reach her.
She was near naked, wearing an adult diaper, and face-down amidst mounds of stuff. Her feet, which were closest to where we stood, were swollen and afflicted with prominent discolorations and skin deformities.
Among the challenges of being an EMT is resisting misanthropy, which almost warrants classification as an occupational risk. In our daily interactions, we EMT’s bear witness to people suffering some of the most dismal conditions of their lives. Often, we encounter our patients at their homes, where they are uninhibited (and not infrequently unclothed), and the tidying pressure of social scrutiny exerts little or no force on their surroundings.
It’s easy to recoil in disgust from scenes like the one Talia and I confronted. The fear of identifying with—of becoming, of being this patient—is so great that submerging that fear in an onslaught of recriminations is a common reflex. How can she let herself live in these conditions? Why doesn’t she ask for help? Why doesn’t she have the discipline/dignity/pride to clean up after herself/buy fewer things/put on some clothes? These kinds of questions, posed in a tone of voice that reinforces superiority and distance from such conditions, can swirl in the current of EMT thoughts and bubble up as fodder for their conversations.
I always try to avoid this kind of gossip about patients—it can be vicious, especially among the burned out, the jaded, and the wounded EMT’s. PTSD is, sadly, not an uncommon diagnosis among us. The first-responder in need of rescuing is, alas, a type. (Occasionally, when I share that I am an EMT, someone asks, “Like Nicolas Cage [from Bringing Out the Dead]?” I hasten to reassure them, “No. Not like him.”) Always, an EMT expressing meanness about a patient’s condition is also articulating self-hatred, an inevitable companion to misanthropy, once it has infected an EMT’s psyche.
Looking at the feces in the bedside commode (smells were filtered by the N95 mask), I felt the misanthropy rising up to challenge me.
But Talia jolted me out of the risk zone.
“Melissa?” Talia was shouting at our prone patient. “It’s me, Talia. Do you remember, I was your waitress from the Golden Savory?”
“Oh yeah, Talia!” the cry floated upwards. “How are you? I haven’t seen you since you picked me up when I fell off the toilet.”
“That’s right! Are you hurt?”
“Just my pride.”
“Wait, I can’t hear anything. Where’s the remote?”
Talia eventually succeeded in silencing the television. Melissa was not hurt and did not want to go to the hospital. She only needed help getting back into her wheelchair.
We assisted her, as she requested. Throughout the process, she spoke to us in a charming, humorous, self-deprecating manner that distracted from the fact that she had taken control of the process and was directing us how to move her (which we appreciated). She interspersed her orders to us with snippets of her life story. She used to be employed and “have a life,” until she was diagnosed with multiple sclerosis, which made her much more dependent. Covid-19 had rendered her necessary interactions with others dangerous. She said she’d declined home health aide assistance out of fear of contracting the virus, and social distancing made it impossible for her mother to take her out to socialize. She wanted someone to shoot her. Then she concluded with a laugh, “We have to stop meeting like this.”
Once back in her wheelchair, she repeated what she’d told us of her life story, but this time she was crying. “I just want someone to shoot me,” she sobbed.
I wanted to sob with her. Another one of the challenges of being an EMT is accepting helplessness. In the usual course, we have capacity to solve only one of the problems we may encounter when we see a patient: how is this patient getting to the hospital? And the answer is what we affectionately call, “diesel therapy.”
For the most part, nothing else we do solves problems. If a patient is having chest pain, we can give aspirin, assist with the patient’s nitroglycerin, and administer diesel therapy; but if the patient is having a heart attack, whatever fix might exist is at the hospital. Likewise for our patients suspected of having Covid-19: we can offer oxygen and diesel therapy, but we have no cure for whatever ultimately ails them.
I did not feel unsafe with Ezra. Although he was considerably larger than me, he conveyed no sense of being threatening or dangerous.In Melissa’s case, we were able to solve her immediate problem of being on the floor when she wanted to be in her wheelchair. That was a success. But with respect to the larger issues, her multiple sclerosis and possible depression and suicidal thoughts, her vulnerability and loneliness under conditions of quarantine, the unhygienic state of her habitat—we were helpless.
Out of a resistance to that helplessness, as well as an impulse for health-promoting interventions that is integral to my nature (and difficult to restrain), and out of a sense of responsibility as a health care provider, and with a smidgeon of misanthropy’s remaining influence egging me to start lecturing, and out of love: for all these reasons, I said, “I can see how unhappy you are. Have you considered talking to a psychiatrist?”
She didn’t use the words, “Fuck off,” in her reply, but that’s what she meant.
Back in the ambulance, after we cleared the call, Talia told me that, even though Melissa needs her wheelchair for mobility and can’t work, she’s independent to a remarkable extent. Talia described their first meeting at the Golden Savory: Melissa had been out with her mom and had ordered a fried chicken wrap and an elaborate mixed-drink cocktail. She’d had such an outgoing personality and good sense of humor that she’d made an enduring impression on Talia, who was waiting tables, working her way through school.
Talia next saw Melissa months later, when Talia responded to a 911 call to assist Melissa, who had fallen in her bathroom at home. “She calls all the time,” Talia said, “and she never wants to go to the hospital.”
Talia added, “When you headed out, she said to me that she knows you meant well.”
*
We drove back to the fire station through dark, quiet streets. The county we serve abuts the city where I live—the border between them is an arbitrary straight line. The area was the subject of a popular television program that depicted it as a festering boil of crime, and the mid-20th century legacy of white flight and industrial abandonment still lingers, clouding general opinion of the area. Nonetheless, the city and its surrounding county have impressed me for being misunderstood and under-appreciated, like the sensitive, open-hearted, African-American poet that I know, who is an officer in the city’s notorious police force.
Home to no fewer than seven colleges and universities, including historically black colleges and a visual arts college, a music conservatory and symphony, world-class museums, a graffiti-mural painting and skate-boarding scene, second-hand thrift clothing shops and independent book stores, a committed “foodie” culture and its expressions at farmer’s markets and in restaurants, recreational parks and wilderness hiking trails, roads that are fun to drive, and drivers who raise the area insurance rates with their recklessness; a racially- and ethnically-diverse group of humans, as well as a local population of deer and foxes; and a quirky, charming friendliness that virtually defines the local inhabitants, the area captured my heart as soon as I moved there. Directly surrounding our fire station was a variegated landscape cut through by highway and featuring peri-urban developments abundant with working-class families, nursing homes and rehabilitation facilities, strip malls, a robust drug trade, half-way houses, jails, neighborhoods under- and unserved, as well as communities of observant Jews, alternating with large spreads of acreage that surround mansions and their attached horse stables.
Asking a suicidal person to go into details may seem socially inappropriate, morbid, or counter-productive, but it’s an important part of the assessment.Beginning in 2016, I had served these communities as an EMT and loved the characters and personalities who allowed me the privilege of helping them. Since the pandemic started, though, fear has stalked these quiet streets on which we drive. Frightened of contracting the virus, and despairing of being separated from family, no one wants to go to the hospital. People are dying at home from strokes, cardiac arrests, and overdoses, mistakenly betting that calling 911 is more dangerous than waiting out whatever they are experiencing. I felt pain that, in this time of extraordinary need, my neighbors in this underdog patch of geography that I loved were too scared to ask for help.
*
If exposure to people in their homes poses certain risks—viral and psychological, our next call swung to the opposite extreme.
Our patient was homeless.
I had been following news stories about homeless people during the pandemic. Many shelters did not afford residents adequate space to practice social distancing. Encampments of homeless people did not, by definition, have hand-washing facilities. Public spaces, like libraries and cafes, that homeless people rely on for sinks, soap, and other services were closed. Homeless people were facing greater difficulty than just about anyone in gaining access to masks, gloves, and other personal protective equipment. Obstacles to accessing health care and underlying chronic health conditions (like asthma and diabetes) among the homeless population created vulnerabilities to Covid-19.
Driving to my ambulance shifts at the fire station, I often passed homeless people standing in the street, holding signs outlining their plights. “Trying to feed my three children,” read the sign beside one woman, shaking her head and on the verge of tears. “Veteran. Hungry,” explained the sign held by an apologetic, but resigned-looking, man. Like so many people, these women and men on the street had lost their livelihood. The sentence, what a ghastly time to—started to form in my head before the ridiculousness of it left me thoughtless. I don’t imagine there’s a good time to be on the street and asking for help.
Our patient, Ezra, was in his mid-thirties. He had presented himself to police saying that he wanted to kill himself. They alerted dispatch, and we were sent on the call.
The site was the parking lot of a mass transit station. Ezra was tall and heavyset. He was wearing a zippered, hoodie sweatshirt, and his hands were jammed into its pockets. The night was cold, and he had no coat. He held his head tilted to the side because of dystonia—a persistent muscle spasm in his neck, the side effect of an anti-psychotic medication he’d been given while incarcerated some years back. The anti-psychotic had been prescribed to treat his schizophrenia. Most recently, he’d been in a residential cocaine-cessation treatment program. It had closed because of Covid-19.
Layered in my personal protective equipment, I handed him a surgical mask to wear. He donned it without affect. Standing under the parking lot flood lights, with a police officer on either side of me, and Talia waiting behind the wheel of the ambulance, I started my assessment:
“Sir, do you have fever, cough, or shortness of breath?”
“Cough.”
“When did it start?”
“Six months ago.”
The time frame seemed too long to be concerning for Covid-19. I persisted, “Do you have sore throat or diarrhea?”
“Diarrhea.”
“When did it start?”
“Six months ago.”
I began to wonder if Ezra was a reliable historian of his own health. Was “six months ago” a default time frame that he used to measure the longevity of conditions that had been around for a while? Possibly he had chronic cough and diarrhea. Or possibly he’d had two symptoms of Covid-19 for a period of time longer than he could track (two weeks? One month?). I’d read of cases that had dragged on with a mild course for a week or more before bursting into a conflagration of severe symptoms.
“Sir, are you feeling suicidal?”
“Yes.”
As EMTs, we are trained to provide care to patients whose presenting symptoms are emotional and behavioral. I know EMTs who find these cases particularly uncomfortable and even frightening. (I once had a patient reassure me, “I’ve been diagnosed with schizophrenia, don’t be scared. We’re not all murderers.”) The stigma of mental illness is formidable, and EMTs are not immune.
I wanted to sob with her. Another one of the challenges of being an EMT is accepting helplessness.I empathize deeply with these patients. I’ve had a fair amount of exposure to suicidal patients because I used to work on an inpatient psychiatric unit. The depth of the suffering is harrowing. The most abiding resonance of that experience is the understanding that: there, but for grace, go I … go any of us. We are all more vulnerable to states of extreme suffering than we had wanted to believe—as Covid-19 has made undeniable.
Now I began my suicide assessment: “How long have you been feeling suicidal?”
“5 o’clock.”
Three hours. “Did something happen to make you feel suicidal?”
“I went to my mother’s grave.”
“I’m sorry for your loss, sir.” I waited. I struggled to interpret Ezra’s non-verbal language—what I could see of his face seemed blank. This paucity of facial expression could be consistent with a diagnosis of schizophrenia. Of course, I am not sure what—if anything—he could read of my facial expression: three-quarters of my face was covered with an N95 mask, and the rest of it was under eye goggles and a face shield.
“Do you have a plan to kill yourself?” I eventually continued.
Asking a suicidal person to go into details may seem socially inappropriate, morbid, or counter-productive, but it’s an important part of the assessment: the specificity of a patient’s plan is an indicator of the extent of the patient’s risk of attempt or completion.
“Yes.”
“What’s your plan?”
“Hang myself.”
“Where?”
“From a tree.”
Given our location in a mass transit parking lot, Ezra had a minimum of a quarter mile walk to find a tree. “Do you have a rope?”
“I’ll get a rope.”
As with the tree, the obstacle posed by Ezra’s lack of ready rope was a hopeful sign. “Have you attempted suicide before?”
“Yes.”
“How?”
“Hanging.”
“When?”
“2011.”
A prior attempt is an indicator of risk. That Ezra could benefit from psychiatric care seemed clear. “Do you want to go to the hospital?”
“Yes.” Ezra abruptly pivoted one hundred and eighty degrees and, with his back turned to me, brought his hand up to his face.
“Sir, what are you doing?” I asked, not sure if I should be alarmed.
He glanced back at me. “Eating,” he said. From under his surgical mask, he produced a drumstick. He had been secreting it in his pocket while we talked.
The situation struck me as funny. I held back a laugh, but I smiled. “Ok, well, finish up, sir. There’s no eating on the ambulance.”
When Ezra had finished chewing, the police—who had stayed on scene for his protection—asked him if they could pat him down, for my protection. Ezra agreed. He had no weapons.
Afterward, Ezra walked onto the ambulance, and I seated him in a chair at the head of the stretcher. As I began taking his vitals, the captain of my fire company materialized in the doorway. He had listened to the progress of our call on the radio and had driven to the call site in the utility vehicle, bringing with him another EMT, Crest.
His blood pressure was normal. He had not coughed the entire time I had been with him. If he had Covid-19, he did not appear to be symptomatic.Cap’s sudden appearance on scene was unorthodox. Vehicles and personnel typically do not respond to a call unless dispatch sends them. Cap had supplanted dispatch and sent himself to the scene. This type of initiative, however unorthodox, was characteristic of him.
“Hey Cap,” I greeted him.
He looked at me taking the patient’s temperature. “Do you want Crest for transport?” he asked, gruffly.
The question blindsided me, and my feelings were legion: jaw-dropping astonishment at his intuition, gratitude for his caring, admiration for his leadership. But just as he’d articulated only the minimum information necessary, I likewise replied succinctly: “That would be helpful.”
We are trained ad nauseam that personal safety is the foremost priority of any EMT. We are never required to transport patients if we don’t feel safe: on the contrary, it’s our job and responsibility to call for help.
I did not feel unsafe with Ezra. Although he was considerably larger than me, he conveyed no sense of being threatening or dangerous. Throughout my interaction with him, he’d given me the impression of being a person who wanted to cooperate to access assistance—including by allowing himself to be patted down. I was comfortable transporting him to the hospital on my own.
But Cap was now offering me the luxury of extra personnel and the concomitant increase in assurance of safety. Part of the genius of Cap’s leadership is his instinct for action that maximizes the safety of the work conditions—and the support that EMTs have to do their job. I don’t know how he decided to show up on scene with Crest. Perhaps just knowing that we were going to transport a patient whom dispatch had described as homeless and suicidal was enough. Regardless, Cap hadn’t waited for me to be in need; he anticipated what I might need and offered it to me.
“Thank you, Cap.”
He nodded and dematerialized. Crest boarded the ambulance. Crest is a talented EMT, and one of the newest in our company. His freshness and enthusiasm were a welcome addition to the atmosphere on board. He immediately struck up a genial rapport with Ezra. To see the two of them seated in friendly conversation, when ten minutes prior, Ezra had been feeling suicidal, seemed reaffirming. We couldn’t do anything to provide him with a home, social support, addiction recovery, treatment for his mental illness, or to restore his mother to him. We were just giving him diesel therapy to get him to a psychiatric unit where, whatever else they provided for him, he would be sheltered, temporarily, from living on the street during the pandemic.
Talia turned on the ignition and steered the ambulance out of the parking lot. I monitored Ezra’s vital signs. He didn’t have a fever. His blood oxygen saturation was normal. His blood pressure was normal. He had not coughed the entire time I had been with him. If he had Covid-19, he did not appear to be symptomatic.
I sat back and started the documentation for the call.
*
Late that night, exiting the fire station at the close of shift and walking to my car, I encountered Argonaut, one of the fire fighters. He was smoking a cigarette.
The first conversation I’d ever had with Argonaut arose from that impulse for health-promoting interventions that I struggle to restrain. Just as he was doing now, he’d been smoking outside the station. I recommended that he quit. His response was much in keeping with Melissa’s, except after the “Fuck off” part, he’d added, “Mom.” It’s a testament to the force of social bonding in firehouse families that we now jokingly and affectionately refer to each other as siblings.
“How was Melissa?” he asked. His voice had some urgency to it. When dispatch had sent us on the call, he’d seen the address. He’d recognized it. He’d been at her house for a “patient assist” before—as recently as two weeks ago. However much he hadn’t appreciated my attempt to improve his pulmonary health, he had urged Melissa to have more home health assistance. EMS supervisors had been involved after his last call. Nothing had changed.
“She kept saying she wanted somebody to shoot her.”
He shook his head.
I had the awareness that two people who might as well have been strangers to Melissa were standing in a parking lot in the middle of the night, caring about her in one of the most fundamental ways any of us express care for someone else: we were worried about her safety. For all I knew, our care had no impact on her life. But it had an impact on ours.
We were helpless. But we were neither of us misanthropes.
______________________________________
Out of consideration for the privacy of the patients we transport, and our company’s members, all efforts have been made to preserve the anonymity of the company. If you want to contribute financially to support our volunteer fire company’s operations during the Covid-19 pandemic, you may do so at our GoFundMe site. We appreciate that financial contribution is not within everyone’s means in this trying time, and we are grateful for any expressions of generosity, be they words of encouragement, good intentions, or your prayers.
