Two frail-looking women sitting on the stoop outside gave us big, gummy smiles as we walked towards the open doorway.
“Top floor,” said the older-looking of the two, as she pointed at the stairs.
“Of course,” I said, with what I am sure was an eye-roll.
The woman laughed. “It’s always the top floor, ain’t it?”
She understood.
The large three-story house had probably been initially built as a large single-family home. Sometime during its history, one of the owners divided the rooms into apartments and eventually, into the current incarnation, subdivisions of Single Room Occupancies (SROs). Aside from these subdivisions, it was painfully obvious that no one had done any serious work on that house for many years.
The door directly ahead on the first floor was wide open, as were most of the doors we would encounter on the way to our patient. Through the door, we could see two men smoking crack pipes, unconcerned with any privacy issues. One of them gave us a friendly wave.
The building turned out to be a very cordial residence with many tenants giving us smiles, encouraging greetings, or at least respectful acknowledgment. All three gestures are a rarity in my experience, and I greatly appreciated them.
Each room had a copy of a handwritten sign taped to its door announcing that $350 rent was due on the first of the month. “No excuses!”
In NYC, $350 is bargain rent, but even so, it seemed to me that these tenants weren’t getting their money’s worth.
We could hear yelling upstairs as we carefully made our way up the treacherous stairs. I’ve been up hundreds, if not thousands, of poorly maintained stairs. You develop a very cautious approach to them, noticing every potential problem for the trip later on, when you would be navigating them with a patient.
The edges, which were once covered in metal reinforcement, were no longer being reinforced, as quite a few of the metal edge frames were without screws and in varying degrees of detachment. Some of them poked outward as if inadvertent booby traps were created for anyone unlucky enough to go beyond the first floor.
Much of the linoleum on the stairs had been worn thin, and on several steps, large chunks were missing altogether. Some of those empty patches had gaping holes underneath where you could attempt to peer into a dark abyss below. A benevolent person had attempted to warn stair users by drawing arrows pointing toward the holes with a thick magic marker.
“Hol”, they read.
The second-floor landing had a curious assembly of possibly discarded items, including a large barbell and a rusty birdcage containing empty light bulb boxes. We could see a skinny blond woman sitting in the hallway doing ‘The Nod’. This is a term sometimes used to describe the fascinating way heroin users will seem to sleepily tilt sideways but suddenly right themselves before falling.
When she heard us, as we made our way up the stairs, she perked up suddenly and gave us her own enthusiastic, tooth-deficient smile.
“Are we here for you?” asked my partner.
“Oh no!” she exclaimed, changing her smile into a serious expression that indicated our suggestion was preposterous. She pointed upward. “Keep going!”
The steps leading to the third floor had concerning stains on the walls that looked an awful lot like blood splatter. Both of us did a bit of wishful reasoning, deciding that it could very well be some sort of food stain. The entire building reeked of large quantities of food long past its expiration date. Perhaps this was a source of some of that stench.
As we entered the third-floor hallway, we were able to make out the words to an aggressive argument we started hearing when we were on the first floor. From the limited snippets of dialogue we were privy to, they appeared to be fighting about the rusty birdcage. The dispute was coming from the right side of the building. Thankfully, a woman behind one of the partially opened doors directed us towards the left side.
As we made our way down the hall, we encountered a disheveled woman. She was hunched over as she walked towards us and had a glazed look in her eyes. She pointed further down the hall and remarked, “Vern went and did a Jimi Hendrix!”
She continued walking while she told us, “I read his autobiography. He choked to death on his own vomit! Just like what Vern’s doing!”
Indeed, as we made our way into the tiny, cluttered room belonging to our patient, we found him lying on his side, his face in a pool of brown, chunky vomit. My partner and I immediately did our best to remove the man from the putrid, foul-smelling liquid as quickly as possible, with as little splash as we could manage.
The patient was a large man, mostly naked, and he was lying on an inflatable mattress that seemed to have a leak. It wasn’t filled enough to make it taut and with the man’s considerable girth leaning on it, it seemed more like a kiddie pool. Moving naked, unconscious people is fairly difficult all on its own. It’s much easier to grab onto clothing or sheets to move someone. This large man, being absorbed into the depths of his air mattress, was especially difficult.
Another skinny woman was in the room with him, and she made an attempt to assist us, which I greatly appreciated, despite the futility of her limited naked-man-lifting skills. We were able to un-wedge him somewhat and attempted to listen to his lungs, but his decreased respiratory rate made it difficult.
He had pinpoint pupils, and his lips were blue. Thanks to some obvious drug paraphernalia found nearby, we quickly diagnosed his condition as a result of opiate use. We quickly got to work administering naloxone, which reverses the effects of opiates.
As we were doing so, we noticed the room directly across the hall also had an open door. Our attention was momentarily directed to a man there receiving oral sex from yet another, frail-looking woman who seemed to have difficulty staying awake during the procedure.
The thin, toothless woman with our patient saw that we noticed what was going on and let out a huge howl.
“DEBRA BE OUT THERE PAYING THE LANDLORD!” She shrieked. It was loud enough for the Jimi Hendrix enthusiast to join her in laughter.
The man getting the blow job seemed mildly annoyed. “You just pay your own rent and stop worrying about everyone else,” he told her.
The blow-job recipient/landlord seemed completely unconcerned that one of his tenants was lying in a pool of vomit only a few feet away. I understand that he could have been preoccupied but, honestly, he didn’t seem to be enjoying himself. Despite the admittedly half-hearted effort going on in that room, he kept paying attention to the activities happening in our room and without much empathy. He didn’t attempt to help our patient even though he could have easily assisted us in moving him. He could have resumed his activities with the woman afterward and she probably wouldn’t have even noticed the interruption.
Our initial dose of Narcan (naloxone) improved our patient’s respiratory rate only slightly. But we were able to listen to his lungs well enough to determine he didn’t aspirate. Another dose of the wonder drug had our man awake and questioning what happened.
Once he came around, the woman that had been in the room with him shook her head and chided the man for taking too much.
“Greedy,” she said as she exited the room.
The man seemed a little embarrassed and told us he had gotten his heroin from a different supplier, and that was most likely the reason why he had taken enough to require a double dose of Narcan.
I cannot explain enough how refreshing it is when a heroin user admits he used heroin. Narcan only works on opioids. If it works, the cause is pretty obvious. The song and dance we go through when people deny it gets exhausting. The protestations are very unnecessary for our purposes.
Most of us in EMS develop a resigned acceptance of addiction as it wastes mental energy to stand in judgment of a large portion of our patient base. Also, over time, everyone becomes just another patient, where you just treat what you find, regardless of how it happened.
There are a lot of people who would have found our location and clientele distasteful, but not me, and probably not most of my fellow paramedics. In fact, at that point in time on that job, this call was turning out to be a great job. The patient was honest, bystanders were (mostly) helpful, and there were shockingly interesting side activities going on; this job had it all. It was also very nice to be in a place where everyone was friendly (except for the landlord).
It turned out that “Vern” was really a man named George. Once awake, he was very cooperative and grateful for our assistance. But he didn’t want to go to the hospital. We asked if he would just let us check him out a little better and perhaps decide later, based on the results of our exam. He found our request to be reasonable.
It turned out George was 55 years old and had just come back home after being in the hospital for over a week, thanks to issues with congestive heart failure. He had a little box overflowing with prescription bottles that let us know he also had diabetes and high cholesterol.
His vital signs were mostly normal, as was his EKG, but we still thought going to the hospital was a good idea. He was adamant about not going. We explained that since we treated him, and he didn’t want to go, he would have to speak with our telemetry doctor on the phone in order to refuse transport. He was OK with the procedure.
We were less so since it meant using George’s phone. We were still in the age of landlines, and George’s phone was covered in a dirty, brown film that was as resistant to the swipes of our cleansing alcohol pads as George’s heroin had been to Narcan.
Calling telemetry for an RMA (Refusal of Medical Assistance) is a long process. There is only one doctor at telemetry for all five boroughs and calls for medication orders take priority. There are other reasons for telemetry contact as well but calling for an RMA puts you at the very bottom of a long waiting list.
We went through the procedure with the paramedic call taker at telemetry who took the pertinent information and then put us on hold. While we were waiting, many of the other residents in the building stopped by to see how our patient was doing. They all universally derided him for not wanting to go to the hospital but George wouldn’t be swayed.
George decided that, while we were waiting, he would get dressed and prepare some food. He was hungry, he told us.
Much of his wardrobe seemed to have been obtained from various hospitals. He had piles of socks with the little rubbery soles and a huge assortment of patient gowns emblazoned with the names of every facility in the city. He grabbed one of the gowns and put it on like a shirt. Then he fashioned himself a sarong out of a stained hospital sheet (also imprinted with the name of a nearby medical facility).
Once his body was partially covered with institutionally stamped fabrics, George made his way down the hall where there was a shared kitchen. He promised he’d return once we were no longer on hold.
He moved much steadier than several of the other tenants of the building as he made his way to the microwave. My partner followed behind while I remained in the small room, listening to terrible hold music while trying not to look toward the oral sex debacle still going on in the room across the hall. You couldn’t really say the woman had stamina, but her persistence in the face of intermittent unconsciousness was somewhat admirable.
I was still on hold when George returned from the kitchen a few minutes later. He came back with a plastic shoebox sized container that had his name written on it in thick black magic marker.
Could George have been the one who looked out for everyone by putting the warning about “hol’s” on the stairs?
He had a determined, serious expression on his face as he rummaged around his room. The woman who helped us lift him from the mattress followed behind him, as did another man.
“What is it you need?” asked the woman.
George ignored her as he continued to look. He was lifting objects and opening containers on the only small table in the room. Then he suddenly stopped.
“WHERE’S MY MONEY ?”
Due to the volume of his voice, he seemed to be asking everyone in the building. A few heads popped out of open doorways.
One of them was the woman who had read Jimi Hendrix’s ‘auto’ biography. “Vern lose his money again?” She directed her question to another face sticking out of another door.
George was furious.
“You know something about my money disappearing over and over?” He marched over to her door.
“No, Vern, no!” she said very apologetically.
“You leave that girl alone,” reprimanded the woman who had helped us. “What you expect when you passed out on dope?”
George marched back over. “What do you know about it?”
All of this back and forth was going on while I listened to the worst of today’s popular hits modified into instrumental sounds designed to remind me I was still on hold. The blow job performance across the hall also remained unaffected by these outbursts.
George started looking for his money in an angry, more disorganized way. He was throwing things around and it didn’t seem that he was trying all that hard anymore.
“Calm down, George,” said a skinny little man.
I’ve always found that telling someone to calm down has the opposite effect.
George picked out a rather large knife from his plastic kitchen box. He waved it around the skinny man. His personality had instantly transformed from a mild and helpful person into a man very intent on violence.
I dropped the phone, and my partner and I moved down the hall towards the stairs. We requested assistance from PD over our radios. A few of the doors slammed shut and became locked. Everyone around George started yelling at him to put the knife down, including us.
George stood still, fuming for a few minutes. But then he tossed his big knife back into the plastic box. He looked a bit defeated.
The oral-sex-bartering landlord finally found something important enough to pause his rent payment. He zipped up his pants and went into George’s room. He took the plastic box and started to bring it back to the kitchen, muttering some unintelligible words in frustration.
George admitted he’d lost control. He apologized to everyone within earshot.
The episode seemed to have been resolved. George looked much calmer, less angry, and the potential weapon had been removed. It was a momentary outburst, probably. Though we no longer felt we were in imminent danger, we didn’t cancel our request for PD.
We slowly returned to the left end of the hall. I picked up the phone handset again and found it to still be playing electronic hold music.
George said he was going to try and fix himself a sandwich again. He was still hungry, even more so now. He blamed his outburst on possible hypoglycemia.
My partner decided to take some of our equipment and move it down the hallway in preparation of our leaving.
He hadn’t gotten far by the time the loud noises started. George and the landlord started physically attacking each other in the kitchen, punching each other, and throwing things. My partner tried to make his way down the stairs when they came closer to him.
I once again dropped the receiver, but this time, as I ran to the stairs, the two men were brawling on the landing.
The events that followed happened so quickly. In hindsight, it seemed longer but while we were experiencing it, it was over in an instant.
As they were exchanging fists on the stairway, the landlord failed to notice one of the magic marker-ed warnings on the steps and tumbled down the stairs after his foot got stuck in one of the open holes. He ended up falling about 12 feet down, landing basically on his head, and stopping right in front of my partner, who was holding the drug bag and monitor with a bewildered look on his face. The controversial rusty birdcage had toppled over with all the commotion and in a strange but not unexpected move, another resident grabbed it and secured it in his room as if he were guarding a long-lost artifact.
Luckily, around this time, PD started arriving. The first pair of cops raced up the stairs after hearing the very loud thud on the third floor landing.
George stood at the top of the stairs with a strange expression on his face. At the time, I thought he might be in shock thinking about the incredulity of the situation but it turned out, a different kind of shock was going on.
Physical shock is when your blood pressure starts to drop, due to a variety of reasons, but the most common is loss of blood volume from trauma. When George turned to look at me I saw his kitchen knife sticking out of the right side of his belly.
We requested BLS assistance (the EMTs) over the radio but one crew was already on scene. They had put themselves on the job when we had first requested police assistance.
We all worked very quickly – us, the EMTs, and the police, to secure both patients to longboards. We bandaged George’s knife in place so that he wouldn’t bleed out even faster than he already was and we quickly established IVs on both of them. I’m proud to say that I got the IV on George on the first try, as he was an extremely difficult person to find viable veins on, given his heroin use.
Fluid replacement is a small stopgap to the surgery he really needed and getting him down those terrible stairs was really the biggest priority. Thankfully, we had much assistance on the scene, but it did take a long time to navigate the stairs with two heavy patients in extremis. By the time we got to the first floor, George needed CPR as his heart had stopped pumping.
Both of our patients required ventilatory assistance, and we put our monitor on George. It showed him to be flatline, which, especially where trauma is involved, is almost impossible to reverse.
Both of our patients had breathing tubes inserted into their tracheas (intubation) en route to their respective ERs. I traveled with George to the hospital with one of the EMTs and a police officer assisting. My partner had a similar crew in the back of the other ambulance, dealing with the landlord’s head injury. Another crew of EMTs arrived to split up and drive us, and another crew of EMTs split up so one of them could drive their vehicle. It was a convoy of units that roared away from that scene.
The landlord was able to go to a trauma center, where we found out later that the severe cognitive impairment from his head injuries would cause him to live out his life in a nursing home. George was pronounced dead in the ER.
Sometimes I think about how, if he had just gone to the hospital in the first place, probably none of this would have happened. His life could have been saved for a completely different reason.
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