The following is part of a monthly series probing the financial and emotional costs of overdose deaths. We welcome reader feedback as we continue to probe this difficult subject.

Addiction caused distance to grow between paramedic Trisha Richter and a family member. Then it brought them back together briefly when she revived the woman from an overdose.

The woman’s infant child was the first to witness her turning blue on the floor, followed sometime later by her mother, who stopped by for an unexpected visit and found her almost dead. She called 911 and scooped the infant from a playpen. Richter rushed in and administered naloxone, an overdose-reversal drug commonly known by the brand name Narcan.

As additional crews arrived on the late June day, the 911 caller held her grandchild outside, shifting the baby from arm to arm while Richter and her partner forced air into the patient’s lungs.

Another woman rushed toward the door as police ushered her back.

“That’s my sister,” she said insistently.

A few minutes later, the woman was breathing but not alert after receiving two doses of naloxone. No one old enough to tell time was present to say how long she was fighting for air before she was found. It may have been long enough to develop a hypoxic brain injury, a condition caused by a lack of oxygen feeding the brain, which can result in severe and permanent brain damage or death.

“It’s sad to see people lose their self-worth and their respect for life. They forget how beautiful life can be,” Richter said from the Fayette EMS Connellsville station a few minutes after she relinquished care of her relative to a medical helicopter team for speedier transport to a Pittsburgh hospital. “I think it’s sad, because to me it’s like playing Russian roulette. You don’t know what shot is gonna kill you, but you know one of them will.”

Repeat patients

Paramedics and EMTs said it’s not uncommon to respond to overdose calls and see a familiar face. Sometimes, they are called to the same home for the same person overdosing multiple times in one day. Patients often refuse ambulance transport to the hospital after they are revived. Although first responders encourage them to seek both short- and long-term treatment, they rarely do. First responders from EMS, fire and police departments all said they have returned to the same house for the same overdose patient twice within an hour. Other times, repeat patients simply overdose multiple times over the course of their addictions. The pattern only stops when the person seeks long-term treatment that sticks, or they die from overdose.

“There was another gentleman – and I could cite you a hundred examples – but we went to his house 10 or 11 times and on the twelfth time we didn’t get there in time. He’s dead now,” said Fayette EMS Chief Rick Adobato.

Reviving a patient with an overdose-reversal drug is effective about nine times out of 10, paramedics said. But it only works if the heart is still beating. If a person isn’t found before oxygen deprivation stops the heart, they must first return a pulse. If a person overdoses alone, they are unlikely to get help in time. In those cases, EMS personnel call a Code 0, print off a strip displaying the stagnant vitals and hand the case over to police and the coroner.

Advanced response specialist Gary Crider with the UPMC paramedic response team questioned whether saving lives is enough when so many patients overdose multiple times, and eventually die before receiving effective treatment.

He said he recently treated repeat overdose patients at at a gas station in North Union Township. The patients were a man and woman in their early 20s with children. Although they were successfully revived just like many times before, this time hit him differently. He wondered what good he was really doing to revive a person who is likely to overdose again.

“I said, ‘We’re losing this fight,’” he said, describing a conversation with another medic on the call. “I just feel like we’re not offering them anything. We wake them up, we save their life, but that’s it.”

Adobato also lamented that reviving a person with naloxone is only a temporary fix.

“Instead of just being able to treat somebody in the short-term until they get treatment, we’ve become enablers somehow in the midst of this,” he said.

More lethal than heroin

Synthetic opioids like fentanyl and carfentanil substantially decrease the effectiveness of naloxone. EMS crews rarely learn what substance a patient was taking when they overdosed. But when a patient does not respond to double or triple the standard dose of two to four milligrams, it is likely the person ingested a synthetic opioid.

“You’re going to a gun fight with rubber band guns. You’re just outmatched, outgunned. There’s no tool in the toolbox for us to really get ahead of the game. So resources are constantly being depleted, we’re tying up multiple ambulances for this and the end result is still not a good result,” said Fayette EMS paramedic Walter Augustine.

Synthetic opioids don’t only present an increased risk to the overdose patient. First responders can overdose by inhaling or touching the drug.

“If we breathe it in, it drops us just like it drops them,” said Fayette EMS EMT Alex Atkinson.

He responded to an overdose call earlier that day in mid-June in Uniontown and saw white powder on the counter.

Connellsville Police Department Cpl. Bryan Kendi said his department recently started carrying naloxone in case an officer comes into contact with a drug, or to use in the rare case of police arriving on scene before Fayette EMS. Uniontown City Police Lt. Tom Kolencik said their officers will soon start carrying naloxone. Uniontown officers have previously come into contact with drugs that caused “very small symptoms” such as nausea, but did not cause serious problems, he said.

State police also carry naloxone. Trooper Robert Broadwater said the drug costs between $16 and $300, depending on brand. Safety protocols for overdose calls have progressively increased. New safety measures for packaging drug evidence without risking contact were recently implemented, he said.

Adobato said Fayette EMS uses naloxone three times more than the other 31 drugs they carry on the ambulance combined. Augustine has treated so many overdose patients he has developed muscle memory for the procedures, starting with safety equipment. He has worked on an ambulance since 1985, back when medics stocked naloxone but rarely used it.

“There was no fear of anything that could harm you — blood, whatever, spit, vomit — you didn’t really worry about it. You knew what your mission was, and your mission was to help that individual that was in need,” he said. “A grain of (fentanyl or carfentanil) can make a difference on whether I pay for my kids to go to college, or my life insurance policy or some GoFundMe account pays for my kids to go to college because I tried to do the right thing by helping somebody.”

Combative patients

Patients themselves pose a risk to first responders on overdose calls. A person who is revived may go from near-death to wide awake and fighting in a matter of seconds. The goal on most overdose calls is to return a person to regular breathing patterns, but revive them gently so they slowly regain consciousness on the way to the hospital. Those who are brought back quickly often lash out physically, typically as a reaction to confusion or fear rather than intentional violence or directed anger.

Atkinson said it is commonplace to have patients kick, punch or spit when they are revived.

Police respond to overdose calls in part to protect other first responders. Kendi said officers often see signs that a patient will become combative. Usually police can prevent an assault or restrain a patient before the person causes injuries.

“You’re there to save a life, so if you end up getting busted up a little bit, it’s just part of the job,” he said.

Kolencik said a woman who overdosed in mid-June in Uniontown became combative and swung at him. He said she later became coherent and said she had no idea she was violent.

Broadwater said overdose scenes become crime scenes in the case of a fatality, but police aren’t showing up to overdose calls to make arrests. The goal is to keep everyone safe.

South Brownsville Volunteer Fire Co. Chief Ron Barry said his volunteers often deal with combative patients. The fire company stocks equipment for medical calls to fill in gaps for EMS coverage and keep a patient alive while an ambulance is en route. While medical calls place an added financial strain and time constraint on an already burdened department, he sees it as necessary.

Last summer, he said a combative patient who was revived from an overdose spit in the eyes of two firefighters. As he was trying to restrain the patient, he injured his knee. His volunteer work cost him 10 days of paid paramedic work with Brownsville EMS while he recovered.

Sapping resources

Adobato said Fayette EMS responded to 13 overdose calls in one day earlier this year. One was fatal. Four of the patients were transported to Pittsburgh by Fayette EMS ambulances.

“That left us four trucks to cover the county,” he said.

On a typical overdose call, two ambulances and two police officers respond. Adobato said between 10 and 14 ambulances are active at any time.

He said many people who are transported for overdoses do not have health insurance, and the non-profit organization rarely receives payment for the calls.

“It takes a whole lot of resources, and we’re losing a pile of money on each one. It’s a vicious cycle that I don’t know if it’s sustainable,” he said.

Fayette EMS Paramedic Jim Hammaker said with an elderly population in Fayette County and high overdose rates, ambulance crews are sometimes called to two emergencies in a short time frame.

“Obviously, it’s very frustrating having to deal with people that are overdosing when it’s delaying you from getting to the people that are experiencing a heart attack or a stroke or something they may not have complete control over,” he said. “That being said, this is our job, and we all understand that there are times when you’re going to be taking care of somebody that has overdosed when somebody just up the street is in cardiac arrest.”

As call volumes increase, he said pay has remained relatively stagnant. He said EMS workers make between $10 and $12 less than a nurse.

“There’s nobody trying to beat down a door trying to work on an ambulance for making the same wages that you can potentially make at a restaurant,” he said.

Running ragged

Adobato said Fayette EMS responded to 346 overdoses in 2017 as of June 22. For each of those calls, medics were joined by multiple police officers and sometimes multiple firefighters.

“There are days when the calls just come one after the other,” Barry said. “We’re run ragged.”

EMTs and paramedics work 24-hour shifts, often working back-to-back shifts while serving with various ambulance companies or working other jobs to make ends meet.

First responders said overdose calls sap resources and energy. But the biggest drain is knowing that many overdose patients will overdose many times over before getting clean.

“I don’t know about anybody else. I just know about myself,” said Crider. “I am tired.”

Paramedics said it is taxing to see lives cut tragically short on a regular basis. But for them, an overdose is just another call with the same goal: to save the patient. Compartmentalizing their feelings is second nature, but Crider said those feelings sometimes sneak out.

“It takes a toll. Our job is to go in, take care of people and then go eat dinner,” he said. “But it doesn’t happen that way when you see a mom that is blue or not breathing and her little 6- or 7-year-old is watching you, and you’re doing everything you can to get her back. And they’re watching the whole time. You only see that a couple times, and it takes a toll on you.”

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