Looking for Death on the Steets
I went to needle exchange to hang out. You may be asking yourself what a soccer mom from the burbs is doing perched on a folding chair in the parking garage of 101 Grove on a dark November night, surrounded by syringes. I was there as a guest observer because I'm working on a series of articles about mortality and homelessness, as part of an Annenberg California Health Journalism Fellowship I received.
Basically, I was looking for death on the streets.
When it comes to the intersection of mortality and home loss, the numbers are overwhelming. There are lots of numbers. Big, scary numbers. But what I really wanted that night was a face. A person with a story and a heart that thumps harder when afraid and a voice that catches when the topic is love. Or home.
Living between the newsracks
Did I find it, in the three hours of watching people cruise into the harshly lit, echoey garage of needle exchange? Did I connect with anyone by hanging out at the fringes of a site where the job is to get in and out and everyone (volunteers, staff and clients) are as wary of strangers as a human can be?
What I found Monday, like the essence of public health itself, was death, and life, and more.
Needle exchange is a simple concept. For all the furor and energy and debate that surrounds it, the bottom line is beautifully concise. That is: if we safely take dirty needles out of our community, we allbenefit. And that concept has been proven true. Over and over and over and over again. But the programs and the people that needle exchange sites serve have come under such fire for so long, and have existed at the frayed edges of tolerance so precariously, that outsiders are generally viewed with suspicion. Even after being introduced as a doctor who works in a clinic for the homeless, I'm greeted with short nods, and an awkward silence. There is no back-slapping, no playing the name-game of which people we might know in common. After all, who knows what I might say, or write – about whom? These are people who've been burned before. After a quick round of introductions, it's clear the perceived threat is not to these peoples' paychecks, since the vast majority are volunteers. The threat is seen as being to the people they serve, to the trust they've slowly and painfully built over years.
Watching clients arrive is a potent demonstration of just how fragile that trust is. It's a cold night, and the early Daylight Savings Time dark gives the night an ominous feel, as though we should be already finished even before we begin. People step quickly down the ramp, fumbling for their small wrap of carefully bundled syringes only after they're well inside. Eyes stay down and everything is held down low, under the edges of the tables. Cotton balls, paper bags, and hand wipes are available to dispense but people only finally look up when a warm "how ya doing?" is offered. A nurse practitioner and an Americorp volunteer are at one HIV table. Two staffers are talking in low voices about overdose prevention at another table.
This is as safe a place as it gets. And still the voices are hushed, the eyes averted. Even with no police, no threat of police, even with warm, caring, non-judgmental staff to greet them, even while in the very act of doing something that is good for themselves and benefits others – even with all that, it is a mostly hunched and hushed interaction. No one, absolutely no one, strides proudly into needle exchange.
It is quiet, and cold, and watching it all I am struck by the body language of the clients, by this visible demonstration of the corrosive shame that is at the heart of every addiction. Sure, there's also fear, and desperation too. But here, where the fear and desperation have been held at bay for a bit, there's only shame left, stripped bare for all to see. It's enough shame, even, to keep a person from getting help of any kind. Coming just to needle exchange, I realize, even with all the protections in place, takes a kind of bravery. As the small woman in the thin black pleather jacket comes down the ramp from the dark alley of Ivy Street, she carries with her, literally, the filth of her habit, hoping to get rid of it. Imagine if you were asked to do the same – to keep and collect every nasty cigarette butt you smoked, every nibble of crap food you ate for a week, and then bring it to a site and show it to others.
Melissa, who's in charge, stays with me, answering questions in a low voice as we perch on folding chairs. The staff is a very San Francisco bunch. Mark, the nurse practitioner, is in his fifties, wearing a t-shirt with a snarling Bella Lugosi covering his chest. Kumar, the Americorp volunteer, is early twenties. The rest of the staff, including Melissa, looks to be all in their mid to late twenties, often variously pierced and/or tattooed, almost all going to school in some version of social work or psychotherapy. Matt, who is staffing the overdose table, is a vaguely familiar face from a couple of years ago when he worked as an Americorp volunteer at our clinic. His nose ring is new, and his eyes seem both gentler and sadder. Or maybe I'm over-reading or misremembering him. After an abrupt "hi, don't I know you?", we don't speak, and he gets busy. Across the parking space behind a table, between silences, Melissa and I discuss "points" (i.e. needles), and hep C.
That's when a woman shouts from the top of the ramp, her voice a thin wail in the cold, "help! there's two men overdosing!"
There's a moment for many people, after any unexpected medical crisis, when your brain stutters, and then tries to insist that it's probably not that bad. I was there as a guest, an observer, a definite outsider – I sure wasn't in "doctor mode," so that's how I was thinking. I watched Mark, the nurse practitioner, and Kumar, the Americorp volunteer, run up the ramp. I expected a head to stick back around the corner and shout "we've got it, it's okay." But no one did.
Then I realized almost instantly what I was doing. Like a flip switching, I stood abruptly up in mid-hep-C conversation and said I thought I'd better go too. I ran up the ramp and down the dark sidewalk, my heavy bag thumping my hip. There, under the shelter of the doorway of my clinic, half a block away, were two men. A small bundle of belongings sat next to each slumped man, and a wispy-haired thin woman in black stood crying, agitated, her hands flapping as she darted forward to look, then backed away as if harshly reminding herself to not get in the way. Or as if she was horrified by what she saw.
By now two more staff were leaning over the men, shouting at them, shaking arms. The man closest to the sidewalk lay flat, the one nearer the clinic door still sat slumped, eyes closed. I bent down and checked the sort-of-sitting man's pulse, which was fast and thready. But he wasn't breathing. At all. I put my hand flat on his chest to make sure there wasn't movement I couldn't see. There was not even a gasp. Not even the slow, tide-like drift of chest wall that signals air leaking out.
Nothing.
He was under so deep, there wasn't even a tiny, residual urge to breathe. Matt, the overdose counselor, had gotten out a syringe of Narcan, the anti-dote, and was putting the soft sponge head of the applicator into the man's left nostril. I told Kumar to get the guy flat, and Kumar gave me a puzzled look and I realized that he didn't really know what I meant, or why. Mark and I were the only medical providers. "His legs," I said, "hold his head while I straighten his legs and let's get him lying flat on his back." Matt gave the Narcan while we moved him. Narcan should work after one dose. Nasal Narcan is "gentler" than the heftier punch of intramuscular or intravenous Narcan, but even so, one dose should do it.
But nothing happened. At all. "Give him another," I said, "and lift his jaw. Like this, Kumar," and then I turned on my knees to the other man lying behind us as Mark worked on him.
I checked that man's pulse in his still warm neck and he too had a fast, thready ripple under the pads of my fingers. But he also had no breathing. No urge, no gasps, no hissing sighs. Nothing ever, not even in response to any stimulation. "He's already had Narcan," Mark said, and I said, "give him more," then I turned back around to the other man.
In a resuscitation, the brain fixes on an image, and it never seems to be the person's face. Maybe it's a neck with its stubble of shaved whiskers, or an unmoving hand with fingers curled like petals. The first man's body became the burned-on-my-mind image of his navy polyester sweat top – the white stripes down his arms were like something Sue Sylvester might wear, but much too thin for the bone-cold weather. There is something so deeply disturbing about a chest that does not move at all that, once noticed, the eye fixates on it, willing it to change.
"We need face masks," I said, "Ambu-bags?" and as Matt pushed another dose of Narcan into the guy's left nostril, I said, voice raised, "has someone called 911?" The entire time I'd been there, kneeling, my right hand had been moving inside my deep bag at my hip, feeling and pawing and ceaselessly handling items. I used to have a foil-sealed face shield that I carried everywhere in my wallet, a kind of doctor's uber-condom for those unexpected moments of mouth-to-mouth. It was only one face shield, but at least that would be one we could use but that's the moment I remembered I deliberately left it back in Haiti.
"I called 911 already," Melissa shouted behind me, over the sounds of the woman weeping. My mental not-breathing-clock was ticking and ticking, the countdown heading to zero and I muttered, hand still on the man's throat, feeling the heart skittering a pulse under my fingers, watching his chest not move, "we need to do mouth to mouth." Mark tilted his man's head back and without pause gave a lip-locked breath to a homeless man lying on the sidewalk. Air rattled and hissed an exhale out after he did. I was moving to put my bag down out of the way when Matt leaned over, pinched the nose of the second man before us and breathed into a crooked-toothed, gummy-lipped mouth. I watched the air seep back out after Matt sat up, the man's lips so loose that they flickered as the exhaling air passed. "More Narcan," I said.
And so it went. Mark and Matt, with quiet dignity, gave breaths to two men who lay on the street, for all purposes more dead than Heath Ledger had been in the hours before he was finally found. There was no "snoring," no dwindling attempts to breath, only too slowly. Nothing. Each of the two men gave maybe one agonal huff of an exhale. Otherwise, for somewhere between 7-10 minutes, and a combined total of at least ten doses of Narcan, they didn't breathe or even try to breathe.
There was one point when we switched to intramuscular doses. One dose after the other, with a pause after each to see if it would work. Two for one man, three for another as the mouth to mouth continued. Once again the navy track jacket became a fixation for me, as I tried to find a bare patch of skin by yanking it to the side. I and Mark stabbed the needles straight in to each man, since we didn't have alcohol wipes. In this setting, an infection is something you hope the person might live to have. It was only after at least five doses each, at least two of them intramuscular, that the man in the navy track top inhaled and then blinked.
Narcan, especially if given intramuscularly or intravenously, can abruptly throw someone into agitated awareness. Or even withdrawal – and rarely that can mean explosive withdrawal, complete with vomiting and uncontrollable diarrhea, face clogged with leaking snot and tears. But after all those Narcan doses, the navy jacket man just seemed to awaken, Lazarus-like, blinking into the faces around him. I pivoted on my knees to the other man right as he also dragged in an inhale, coming to after an additional dose, and more slowly.
That's when, only after they blinked and breathed and shifted, that's the moment both the ambulance and the fire truck shoved into the curb at our backs.
And all hell broke loose.
Stay tuned! Who got into trouble – and for doing what? And what exactly in heavens name did these men take? Do they survive it? Find out the rest of the story this Thursday, but in the meantime, share your take about what you think happened in the comments sections. And stay tuned for the Annenberg California Health Fellowship's series by Doc Gurley on homelessness and mortality. There will be an article every Tuesday – find out who's dying in your neighborhood, what's being done about it, and what you can do to help. This project is made possible through the Annenberg/USC California Health Journalism Fellowship, with support from The California Endowment.
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