Gunpowder on the street
This is part two of a series of articles examining the relationship between housing loss and death in San Francisco.
In tandem, both ambulance, and fire truck, red lights strobed across the narrow cave-like doorway to the Tom Waddell clinic. The images flashed in the dark, like red-tinted, stop-motion animation. Inside the narrow space the six of us from needle exchange creaked zombie-like to our feet from where we'd been bent over bodies. Two men still lay flat-backed on the cold concrete, only now beginning to twitch and jerk, and enough torn packaging fluttered that it looked like someone had tossed the contents of a recycling bag of paper into the doorwell. Between the two men, we'd given about 10 vials of narcotic antidote (Narcan), over at least ten minutes.
It may have been longer. When you're doing a resuscitation, time rubberbands out thin and tense, the spaces widening between your own heartbeats, everything stretching all the way to the breaking point. And then, with that one gasped inhale, time snaps, stinging, back to normal.
We had witnessed at least ten minutes of no breathing - not counting the time it took before we arrived for the men to go under, plus the time after for the wispy-haired, weeping woman to realize what was happening and run down the block to the garage of 101 Grove, shout to us for help, and then for all of us to run back down the block, give a dose of Narcan to each man, wait for a response, and then, finally, begin rescue breathing.
No matter how you look at it, that's a lot of not-enough-breathing time for anyone's brain. Believe it or not, an entire field of study exists among cost-effectiveness researchers devoted to quantifying, or putting an exact number on "fates worse than death." Certainly, for me, global anoxic brain damage ranks high on that scale. For these men, I had to wonder if, when they came around, they would be, as we say in medicine, "all there."
That was the stinging question. The lights continued to strobe behind me as I sensed men in uniforms talking and crowding and I didn't realize I was holding my own breath until the navy tracksuit-top guy tried to sit up. He was moving and groggy, but it looked, crudely, as though he was mostly okay. The other man still lay on the concrete, frowning and blinking.
I could feel my own breath gust out and my heart give a thump as I realized maybe it was going to be okay. And we all seemed to realize it at the same time, as though the rubberband of time had gone all jiggly and loose. There were other Civic Center homeless people on the sidewalk behind me. A wild-haired scarecrow-thin man with tattered clothes and his arms crossed over his hunched chest reached out and gave a tug on the sleeve of the still-weeping woman. "It's okay," he said to her and then nodded in my direction, "here, you (gesturing to me), you tell this woman it's going to be okay." It was as though he couldn't bear to watch this woman's anguish any longer - now that the two men looked like they were going to recover, he wanted me to reassure her. Now.
But she looked up at him, confused and only saw another street person, dark and fierce in his frown of concern and she jerked her elbow away as though stung, too emotional to understand what he meant as she shouted at him, backing away, "Don't! What are you saying? Leave me alone!"
The thin man flinched. Firefighters milled around, the paramedics from the private ambulance company were pushing forward and the concerned homeless man got a panicky look, his arms re-crossing over his chest and his eyes darting from me to the men in uniform as if he just realized he was exposed, that he might get in trouble. He tried to back away, but had nowhere open to go, muttering in my direction, "I just wanted you to tell her..."
Like so many times on the street, with people who are fragile and traumatized and emotional and desperate, it felt like the whole situation could blow with only the slightest provocation. I stepped forward toward these two as the paramedic moved in past me to the recovering men. Melissa, in charge of the needle exchange site, had veered around to the weeping woman, also sensing the emotions rising to a crisis. We told her it was going to be okay, that this man, her "harasser" only wanted her to know the guys who'd overdosed were coming around. In the push of bodies I turned to thank the fierce sidewalk man but in just a flicker of time he had already fled.
Voices behind me rose, someone shouting and then more cars came, people brushing and shoving in the small cold space, staff bending and straightening in flashed robotic images as they picked up the trash. Both recovering men were standing up as people bumped back and forth against each other and the weeping woman, her face still stretched into a taut grimace of emotion, suddenly darted forward into the densest part of the crowd and wrapped her spaghetti-pale arms tight around the waist of the now-standing man who had been slowest to respond, her head only coming to his chest as she hung onto him as though she might be swept away. Now police cars were pulling in and a man shouted "who's in charge here? what's going on?"
More police arrived, I saw two, three (now was it four?) in uniform, milling back and forth between the firemen and the private ambulance paramedics. One of the police said, angry, "which one's the doctor?"
I moved to the edge of the crowd, "that's me."
The staff from needle exchange drifted toward me, knowing glances shared between each other.
One of the major challenges of treating overdoses is the helper's fear of law enforcement involvement. People are afraid that when they call in a moment of panic, afraid that someone might die, that the police will use that as a chance to raid their belongings, revoke their parole, or send them to prison on a new drug charge that could forever alter their life, their job, their access to their children. Overdose prevention training tries to encourage people to take that chance.
As the cop wove through the crowd toward me, I didn't know what he wanted, but even knowing I hadn't done anything wrong, that I wasn't vulnerable, that there wasn't anything outstanding in my life for him to find, I still felt that frazzle of nerves that borders on fear - that feeling you get whenever an adult man is physically or verbally aggressive toward you, whether it's a road-rager gesturing at you, or a customer service person sneering over the phone. It is a clenched-jaw emotion.
To his snapped questions, I responded. "I am a doctor," I said. "They're with needle exchange." "This building is the clinic where I work." I kept my voice level and even warm, but my answers and explanations didn't seem to reassure him. As he left, one of the staffers muttered after his retreating back, "You're welcome."
That's when I found out that the private ambulance driver, had told the navy track-suit man, moments after the man had come to, also in an aggressive tone of voice, that he MUST to go to the hospital.
This is, indeed, strictly true. The antidote the men had been given, Narcan, commonly wears off before whatever drug the person took. That could result in a person relapsing into a non-breathing state, long after others have left. You might think the average person, knowing this, would climb right in the ambulance. Maybe not, though, if you're worried about the cost of it all. Or the drugs in your bag. Or the risk of losing all your unattended belongings back at your site. Or you're just confused, or you think you feel fine and you don't know where all these people came from. Or any of a number of different reasons. The paramedic, when the groggy tracksuit man didn't seem to want to go to the hospital, had grabbed the front of his shirt in his fist and said that if the man didn't get in the ambulance now, he was going to call the police. And then the paramedic apparently did call the police. Hence the mass-arrival of law enforcement in force.
That's when, at some point, our patient - the recovered navy tracksuit man who was reluctant to go to the hospital - slid away into the dense dark of the alley. "What was he wearing," the paramedic barked at us. "Does anyone remember what he was wearing?"
"You'll never find him," Mark said, his voice flat with disappointment. Learning all this, my mouth was dry with stress, an anger simmering at how the situation could have been managed better.
"But he's going to drop dead out there," the paramedic said, his voice strained. "When the Narcan wears off won't he stop breathing?"
"Yeah, he might," I said. The stricken look on the paramedic's face gave me a flash of guilt. "Depends on what it was he took." The paramedic's heart may have been in the right place, but what he'd done had escalated a tense situation. This was the type of problem where the nurses at my clinic - the Tom Waddell clinic - often show gifted-level interpersonal skills by talking someone down as opposed to setting them off. It's hard for people outside the world of the marginalized and broken and betrayed to understand how fragile and ephemeral the tie to getting help can be.
Why can't they just get help? Why won't they just go to the hospital if they need to? Why won't they just...
Even without the fear of being busted for having drugs in your bag, even without a distorting cloud of paranoia or mental illness, for so many people, a fist holding a shirtfront is all it takes, after even a few weeks of damaging existence on the streets, to make you think maybe you're better off on your own. And bolt.
There was a second round of questioning for me from the police, who wanted a copy of my license. This time the officer pulled out what I think of as the Pen of Intimidation, and clicked it in my direction with a flourish ("so who did you say you are? A doctor?") before he began to copy down my info into his Notebook of Authority. So what kind of doctor? And what was it I give those men? How much? With a needle, was it?
Honestly, in my years and years of experience interacting with them, SFPD is actually quite excellent in this kind of situation. So I'm not sure why now was so different, other than maybe the obvious fact that I didn't have a white coat, stethoscope or clinic atmosphere to drape myself in. Or maybe it was purely the gothic weirdness of the situation - a gang-resuscitation, inflicted in a dark alley on two random men by us, a roving, antidote-giving resuscitation mob.
Maybe it was the thundercloud frown directed at me, or maybe it was a post-resuscitation reaction, but I had to keep reminding myself to stick to just the question and not babble.
For the first time, deep down, in a way I'd never done before, as I stood there with nothing to fear, but feeling a vague, threatened fear anyways, I truly understood the tremendous challenge that the overdose prevention counselors face. Scoff if you want, but until you've done it, it's hard to realize how hard it is: facing the police in a near-death situation is not easy. Overdose counselors must connect with people in a deep way, gaining trust and plausibility - overcoming the fear that must be overcome, giving the tips and reassurance that people need to do the right thing.
It was hard not to think about just how easily things could get ugly. One snapped response, one bad outcome - I was painfully aware that I wasn't covered for my actions. I was on my own time. Governor Schwarzenegger even recently vetoed a bill, AB 2460, to protect Good Samaritans from criminal prosecution for minor drug crimes if they call to save someone's life from an overdose death. At least I could honestly answer the police that I didn't know what it was that the men took.
When the cop stepped away, though, I found out. "Gunpowder," is what it was. A mix of Fentanyl and black tar heroin. Gunpowder showed up in Chicago four years ago, resulting in 342 fatalities. Only 43 people made it to the ER, where they required large doses of Narcan. Then, the substance became known on the street as "Drop Dead." A nurse friend of mine who worked in a Chicago ER at that time, told me there was "a run on Narcan then, paramedics trying to bum some off the ER because they'd run completely out, everyone not having enough and worried about where to get more." I realized that if the overdose prevention-training staff hadn't been on site at needle exchange, we would never have had enough Narcan to get the men to come around. What if we'd been standing there with only one vial?
The fact that it was Fentanyl was hopeful news for the man who slipped into the darkness and left. Fentanyl is a shorter-acting opioid, so his odds of surviving the night after the Narcan wore off were tilted a bit better. He still might succumb an hour later, out in the dark somewhere, but at least he had some chance.
The overdose prevention project has saved at least 500 of San Francisco's lives since it began. Our two men that night aren't in that count. It's standard cost-effectiveness strategy to assign a break point for a reasonable dollar cost to be that of $50,000 per year of life saved for any intervention. Less than that is "affordable." More than that and you've got to either reduce the cost, or "quality adjust" it to make the numbers more appealing. Given that standard, and the fact that our men looked to be in their thirties, and assuming most of the people saved are about that age, even if you assign a much-shortened future life expectancy of only 65 years after treatment...well, that means this one, two-staffer, folding-table program with carefully built trust and warmth, is worth at least (drumroll, please)...an eye-popping $753 million dollars. Not too shabby.
I'd come to needle exchange that night hoping to learn something about death on the streets, the important work being done, and why some people survive and some don't. Surprisingly, studies across the world consistently show, despite my experience that night, that substance abuse among the homeless is not actually a major risk factor for early mortality. So what is it, then? Why do some people die so young and so quickly, and other don't?
I'd come to needle exchange an outsider, a tolerated observer, there on forbearance. But now the striking difference after this experience together, the shiny-new, truly warm camaraderie, made me aware of its heat, the way connections between people warms and thrums, powering life itself. I walked over and asked Matt if he wanted a piece of gum. He said, a pink-cheeked smile at the ribbing of his colleagues, "Oh, boy, would I ever." After the others drifted away, I encouraged Matt to get tested the next day, even though his risk of catching any kind of infection from mouth to mouth was almost non-existent. Matt said, "Sure, I will, but my theory is, if you're going to get infected with something, there's no better way to do it."
I noticed then that Matt's gaze was fixed on the second man who still stood next to the open ambulance. Tonight, two young men were alive, with no signs of brain damage, because of the quiet heroism of Matt and Mark. Without intervention, they might have been fated to join the ranks of Heath Ledger and Michael Jackson and Anna Nicole Smith and way, way too many others.
Despite the influx of police, the second man hadn't fled - he was going to the hospital. He stood, swaying a bit, the blanket-cape of paramedic-care draped across his shoulders. The weepy woman still clung to him, her thin arms tight as a belt around his waist, her head pressed tight to his breastbone. He had tears on his cheeks and the woman was muttering, "you almost died" over and over. He was alive, truly, because of her. She was the one who realized what was happening. She was the one who came and got us. She was also, most likely, the real reason he was going now to the hospital, instead of darting into the darkness like the other man.In the onslaught of injury and trauma and infection and exposure and suffering on the streets, could these two men, and what had happened tonight, be a symbol of why some live and some die? Could it be, in the end, as simple, and as complex, as that?