Paramedic Mary Taylor weaves the EMS truck through downtown Louisville on a typical weekday afternoon, juggling radio traffic and scanning the streets for trouble. That’s when the call comes in.
A 30-year-old man is unconscious in a house off Dixie Highway. He’s not breathing. It’s probably an overdose.
Taylor knows it’s about four to six minutes before a brain injury sets in. Not long after that, the chances of death are much greater. Minutes matter.
Taylor types the address into her GPS. Right now, the 30-year-old man is seven minutes away.
She steps on the gas pedal, turns on the siren, speeds through a red light and takes a hard left onto the highway.
For the 20-year EMS veteran, it’s another day and another possible overdose.
***
This kind of emergency happens day in and day out in Louisville and in communities across Kentucky. Heroin is now commonly laced with a more fatal drug called carfentanyl, which makes death more likely.
To fight this, paramedics in Kentucky administered 10,000 doses of anti-overdose drug naloxone in 2016, according to the Kentucky Board of Emergency Medical Services.
In the first two months of this year, Louisville EMS administered these drugs to 703 patients. That’s more than triple the total from the same time period last year, and a nearly seven-fold increase from 2015.
“It’s futile, what we’re doing,” Taylor says.
And there’s no sign of it letting up. Taylor hasn’t seen a dent in overdose calls despite efforts by the city or state. Those include the Louisville syringe exchange, expansion of treatment centers like The Healing Place, Kentucky’s needle exchanges or stocking up on more reverse-overdose drugs.
Taylor believes one best effort — a law that put in place the Kentucky All Schedule Prescription Electronic Reporting system (KASPER) — has partially led to this dilemma.
Doctors were required to report all opioid prescriptions starting in 2014. Although the goal was to stop the tide of overprescription that was getting people hooked, it led to a reduction in prescriptions and a move by many to heroin.
Heroin is an opioid that is much stronger than the OxyContin anyone was taking. And heroin now has Taylor weaving across the interstate to try to save another man’s life.
***
“He’s going to be completely out when we get there,” Taylor says.
She pulls up to the house and finds five police officers, two EMTs and two firefighters. The police already shot him with the anti-overdose drug Narcan. But he’s unconscious and not breathing, and for the police version of the drug to work, a person has to be breathing.
Taylor has been to this home before. The one-story house looks well lived-in, with an address plaque bearing a University of Louisville cardinal with gritted teeth.
Inside, the man is lying on the floor. He’s on his back, next to a twin-sized bed with a purple and pink patterned comforter. Taylor asks the police when the last time anyone in the house saw this man. “Twenty minutes ago,” they answer.
Taylor and four other first responders cram into the room. Someone plunges the needle into his arm, shooting him with Narcan.
There are moments when the only sounds in the house are of the defibrillator’s compressions, machine-like ticking, as it tries to restart the man’s heart.
***
Death is often seen as the worst part of heroin and other drug overdoses. But for every person who dies from an overdose, many more live. And the living itself can have consequences.
When a person overdoses, their heart goes into cardiac arrest: It stops. The lack of oxygen can cause a stroke or injuries to the lungs. That can mean a nursing home, a 24/7 caregiver, physical rehabilitation or speech therapy.
“Even for people who say, ‘Let them all die,’ it’s not that simple,” said Shawn Ryan, president and chief medical officer at BrightView, a treatment program in Cincinnati. “Most people actually survive, and some of them do have lifelong health consequences, which is very expensive to the medical system.”
***
Taylor has been giving the man care for 15 minutes and 18 seconds.
She says he threw up unconsciously in response to Narcan. The heart rate monitor is almost a flat-line.
“He’d already vomited, he’d aspirated, which meant all that was probably in his lungs,” Taylor says.
The medics put a black tarp underneath him. Several first responders lift him up and carry him through the house and into the ambulance. Neighbors gather outside.
“That’s what I don’t get,” Taylor says later. “When you see it in your community, you see all these people, they all come out all the time. Why do you continue to do the things that you do? I just don’t understand.”
But she does. It’s addiction.
***
In the time Taylor and her counterparts were trying to save the man’s life, there was another overdose that required EMS assistance.
In most of the U.S., heroin addiction is treated by nonprofits, through grants and in private rehab centers for people who can afford it. Here in Louisville, there are numerous nonprofit treatment centers, but none are linked up to what some call the safety net of the safety net: paramedics.
The institutional powerhouses — hospitals, primary care clinics, government and insurance companies — aren’t really engaged in treating drug addiction in the same way they are physical illnesses like diabetes or stroke.
“You would never diagnose someone with a heart attack and then give them a cardiologist’s card and say, ‘hey man, you should call this guy tomorrow,’” said Ryan, the Cincinnati ER doctor.
Hospitals across the country once offered 30-day detox treatment in-house, but that went away by the 1990s, when insurers found drug users were cycling in and out without positive results, according to Ryan. Nothing has taken the place of that for people who are taken to the ER after overdose.
But a new concept has taken root in some places: community paramedicine.
Paramedics work to engage residents and prevent emergency calls. The approach so far has focused mainly on the elderly. Kenneth Williams, chair of the National Association of State EMS Officials, said EMTs are well-suited for outreach to drug users. But there need to be resources and financial support to use community paramedicine for addiction interventions.
There are some cities integrating EMS into drug treatment, and they have a lot in common with Louisville.
Take Cincinnati, where officials have also noted large upticks in heroin overdoses because of carfentanyl. The county government recently started a program where a police officer, a paramedic and a social worker go to the scene of an overdose a day after.
Even if the overdose patient isn’t there, there are likely people in the house that may be users or have regular contact with that person. The team asks if the person is interested in treatment, if they have transportation to treatment and other things that stand in the way. So far, the results are positive.
And in Baltimore, nonprofit Behavioral Health System Baltimore is setting up a stabilization center where EMS will be able to take people who overdose if they don’t want to go to the emergency room. BHSB got state funding and the center is expected to open next year. Baltimore has also seen increases of overdoses due to heroin.
Kentucky is still in a stage of community paramedicine that hasn’t extended to drug users.
In Jefferson County, four EMTs are dedicated to so-called super-utilizers — who call 911 multiple times a week for non-emergencies. And in Oldham County, EMS teams are trying to prevent people from being readmitted to the hospital after surgery.
Mike Poynter and his team got a small grant from the Kentucky Office of Rural Health to start pilot projects that put EMTs in the new role.
“It’s a new extension for EMS that we’re trying to be proactive rather than reactive,” said Poynter, executive director of the Kentucky Board of Emergency Medical Services. “We’re training them to be more in preventive medicine. And that’s not our true specialty, but it falls into the category.”
This project isn’t focused on drug users, but there’s potential to expand it. Their goals include getting fewer calls and fewer hospital readmissions. And Poynter said if the results are successful, KentuckyOne and Baptist Health might start paying local EMS services to do these things on a much bigger scale.
Poynter said that could extend to the program targeting drug users.
***
Back in her Louisville EMS truck, Taylor’s cellphone rings. She gets these calls after almost every overdose.
She’s thickened her skin for these calls, the deaths and trauma she sees every day. Still, it gets to her.
“I met this lady the other day who had overdosed, and she was awake by the time I got there. She was really nice. I asked her about her kids, and she started crying and she said, ‘I can’t stop it,’” Taylor says.
The plea for help almost brought Taylor to tears.
“You hear all these negative things, how all these people that overdose are awful, terrible people who live on the streets and have no families, and that’s not true,” Taylor says. “These people have a history. There’s a reason that they’ve started using.”
Taylor continues to drive, cellphone pressed to ear. On the other end of the line, a voice says her most recent patient has been pronounced dead.
