Medical Emergency? Philadelphia’s Fire Department to the Rescue

SHANOOR SEERVAI: Hi everyone, welcome to The Dose. This is the second of our three episodes on disparities in health care. Today, I have Crystal Yates with me from the Philadelphia Fire Department. Crystal is on the front lines of our health care system — she is responding to emergencies every single day. Last year, she became one of the first experts to receive the Pozen Commonwealth Fund Fellowship in Minority Health Leadership at Yale University. Crystal’s work is focused on finding innovative ways for the fire department to help people when they have no other resources to turn to.

For today’s episode, we are going to take you on a journey through a day in the life of the Philadelphia Fire Department’s Emergency Medical Services system. Crystal, welcome to the show.

CRYSTAL YATES: Hi, thank you so much for having me. I’m happy to be here.

SHANOOR SEERVAI: To get us started, could you tell me, is it really common for fire departments to be dealing with medical emergencies? Or is this something that Philadelphia is doing that is different from other cities?

CRYSTAL YATES: So, I’ll start by saying, and there’s a saying in EMS, it goes like this — when you’ve seen one EMS system, you’ve seen one EMS system. So the country has several different EMS models; some of them are fire-based, like ours. Some of them are hospital-based. Some use privately owned ambulances. So it is very common for fire departments to respond to medical emergencies and that’s what we do here. In Philadelphia, we are the sole 911 responders for medical emergencies. Meaning, anyone that calls 911 for a medical emergency will get the fire department to respond.

SHANOOR SEERVAI: And what kind of medical emergencies are you responding to most often?

CRYSTAL YATES: Wow. That’s a good question. So in Philadelphia, we have a very, very busy system, we’re high volume. Last year we responded to just under or around 300,000 calls over the year. And then we took maybe 200,000 of those to the hospital. We respond to everything from people that are in cardiac arrest, trauma, gunshots, stabbings, we respond to people that overdose. We respond to chest pains, strokes, and anything that the doctor would see in the emergency room, we respond to it.

SHANOOR SEERVAI: And so you said that last year you responded to 300,000 calls. What does that mean on any given day?

CRYSTAL YATES: So on any given day, that is on average we respond to 850 to 1,000 medical emergencies, with 55 ambulances. We use to measure the system what’s called unit hour utilization.

So for instance our busiest medic unit happens to also be the busiest medic unit in the United States. Medic 8, who works on the Kensington area, their UHU during the daytime is always at 1, meaning they are 100 percent of the time of their 12-hour shift responding to medical emergencies.

SHANOOR SEERVAI: Wow. How do they possibly keep up with that, sustain that momentum over 12 hours?

CRYSTAL YATES: It’s difficult. It’s difficult. And that’s one of the things as the leader here that I struggle with. I mean, our workforce basically can’t take a break. Like, they don’t get time, we don’t give them breaks for eating, we don’t give them breaks for the basic things that everybody else in the workforce gets, because we’re responding to these 911 emergencies. So when they come in to work in the morning — I’m going to give you a typical day when I was a paramedic myself working in the field. We would come into work in the morning, perhaps get a cup of coffee, and while we’re drinking the coffee, we’re checking our ambulance or our rig or our medic unit and we’re making sure that all our equipment is up to par, our defibrillator’s batteries are charged and ready to go, our narcotics are safe and secure, and we have everything that we need to go. Many times, while we’re checking, we get dispatched to a run. And we get dispatched to a run, we respond and we sometimes see what it is when we get there. I’ll tell you our highest number of calls are for quote “sick” or unknown, and that means either the caller was unable to adequately describe what was going on, or there was just a translation issue like if the dispatcher cannot determine what we’re going for they will mark it as sick unknown.

SHANOOR SEERVAI: Crystal, could you give me an example of one of the cases that you were taught maybe as a paramedic when you got a sick unknown and it was just very challenging for you to work through?

CRYSTAL YATES: Yeah [laughs] I could probably give you several examples, but the first one that comes to mind for me is a call that my partner and I had. I worked in the city’s Hunting Park section. It was late at night and we knew the address to the facility that we were going to. It was a senior citizens apartment complex. So we get a call for sick unknown on the fifth floor. We responded to that call, and we’re bringing our equipment inside, and we walked into the lobby of the apartment building and two gentlemen like, rushed towards us and they were like, “Hey, hey, the run is outside in the courtyard.” Which confused us, because we were like — how is the run outside in the courtyard? So we go out into the courtyard and find that in this senior citizen complex, apparently one of the seniors, her grandson was visiting her, and he was having mental emotional problems and he jumped from her fifth floor apartment window outside and attempted suicide. And here we think we were coming for, you know, maybe an elderly person that’s having something that’s not, you know, traumatic, and we have to kind of reset and get ready for a trauma. So I had to run back outside and get the trauma equipment, the back board and, you know, get our stretcher and everything ready to take care of a trauma case.

We had to call for police assistance, and the police came and they were able to calm things down and we were able to treat and take care of this young man and get him to a trauma center. And this was at least 15 years ago. I hope that he’s doing well. But that’s another challenge of the job, too, is that we don’t frequently know the outcomes of our patients.

SHANOOR SEERVAI: So you sort of have two kinds of cases. One it sounds like are the one-off emergencies that we talked about where you don’t really get to see what happens to a patient. You just go and you deal with the emergency and you’re out. But the other are people who are repeatedly calling 911. Why would somebody be calling 911 every day?

CRYSTAL YATES: So we had a person, Linda. Linda would call 911 two times every day. Our field supervisor referred Linda to us, and they said listen, this patient is calling twice a day and she’s calling because she needs the fire department to in the morning get her out of her bed into a chair, and then in the evening, get her out of the chair and back into the bed.

And we were like, wow, really? We found that hard to believe. So we ran the data, we looked at the numbers, and then in fact this address called at least once a day and sometimes twice a day. So we went there — myself, I was a captain at the time with my lieutenant, we went to this home to visit Linda. And when we went to visit Linda, we found a lady that was in a back bedroom. It was pretty dark and dingy. We introduced ourselves and asked her — what is it that’s causing her to call 911? Well, she had a history of multiple sclerosis. She was wheelchair-bound. Her wheelchair was not working at the time. We learned that her home health care aid was not showing up to work.

So Linda was left home alone a lot and nobody knew it. So that’s why she relied on 911 and the fire department to just at least get her into the bed and out of the bed. So she was a long case, and we don’t have the manpower or the person power to deal with complex cases like this often, but we did help Linda.

SHANOOR SEERVAI: Okay, so what was the work you were doing with Linda day after day to help her recover?

CRYSTAL YATES: We reached out to the MS Society, they were able to donate money to her to get her wheelchair repaired. We reached out to her insurance company and the home health care agency to get that home health aide replaced. And we went to close out Linda’s case, you know, this was probably over six months. And she was a different person. She was up, her apartment was well lit, she was sitting in the wheelchair, her home health aide was there making breakfast. Her medications were lined up perfectly on the table and she was doing very well.

SHANOOR SEERVAI: It sounds like there was a real need that nobody else in the health system was able to recognize, and it took you going into her apartment and seeing the reality that she was living with to help her?

CRYSTAL YATES: Exactly. Like I always say, we’re the boots on the ground. Like we see the things that are truly happening.

SHANOOR SEERVAI: So we know that in the state of Pennsylvania, more than 44 people die from drug poisoning for every 100,000 of the population. That was in 2017, and that actually was worse than the previous year. So Pennsylvania is the state with the third-highest rate of drug fatalities in the U.S.; only West Virginia and Ohio are worse. And Philadelphia is a city of 1.5 million people, so I imagine, you know, that’s more than 10 percent of the population, I imagine that the opioid epidemic in Philadelphia is a really big problem and something that you’re dealing with all the time.

CRYSTAL YATES: We are. So in October of 2018, Mayor Kenney did an emergency executive order putting together the Resilience Project. And what he did with that was he got several of the agencies that worked directly for the cities together to work on the opioid epidemic. Our epicenter of the opioid crisis is in a neighborhood called Kensington. I want to transport you there in October of 2018, because there have been several changes since the Resilience Project started. But in October of 2018, Kensington was a neighborhood that was — the workforce is basically, you know, working class, people going to work, kids going to school. There’s a lot of hustle and bustle because there is an elevated subway line right there going through the Kensington area, and if you picture this elevated subway line, there are overpasses. And under probably five of these different overpasses were large communities, tent cities, of people with substance use disorder, all living together, all utilizing drugs together right there in these encampments. And there were at least five major encampments in the city at the time. So debris from the drug use, imagine that all strewn through the streets. Children playing in and around these things. And it was bad. So the mayor did this executive order putting the Resilience group together.

Now, Kensington is still an issue, but there are a lot of resources that are in and around the Kensington area. It’s getting better. Is the problem gone? No. But we’re all working on it and we’re working very hard on the problem.

SHANOOR SEERVAI: How many overdoses do you see every day in the city or specifically in Kensington?

CRYSTAL YATES: We get about anywhere between 10 and 20 per day in the Kensington area. And then in the city overall, we may get up to 40 a day.

SHANOOR SEERVAI: Wow. That’s a lot of cases. Now, the first time we spoke, you talked about how you have a multidisciplinary team because you really need a full range of responses based on what kind of treatment someone wants. So maybe somebody says they want to go to the hospital, someone else says, no, I don’t want to go to the hospital. Somebody wants Naloxone. Somebody doesn’t want treatment at all. Talk to me about the importance of having so many different kinds of people with different expertise on your team.

CRYSTAL YATES: So picture, we get a 911 call for someone who’s overdosed, we respond to that call, we treat the person with Naloxone, sometimes they do want to go to the hospital and sometimes they don’t. About 20 percent of the people we were finding refused care after that. They did not want to go to the hospital. So one thing that my providers, or I was hearing from my providers is that, you know, they felt bad, they felt like they couldn’t do more, like they’re just going out and they’re administering Naloxone and that’s it, they’re going off to the next call. That prompted myself and other partners from the health department, the department of behavioral health, to get together and talk about doing something different. And we came up with this idea of an alternative response unit. And this unit is a fire department vehicle, it’s an SUV, and in that SUV we have a paramedic lieutenant and we have a behavioral health case manager. We also have a full-time social worker. So when that person refuses to go to the hospital, this alternative response unit, I’ll call it AR2 from here on out, because that’s his call sign here in Philadelphia. AR2 will be dispatched or they will hear this call while they’re roaming around Kensington in their SUV.

And when they respond to this call, their role is to offer connection to other services to this person. So “Are you ready for treatment?” you know, is one of the questions, and as far as EMS goes, we know how to treat people, we know how to take them to the hospital, we literally save lives, right? But we don’t have a lot of background in the behavioral health part of substance use disorder. So when we were putting this unit together, it was important to have behavioral health experts or subject matter experts working with us.

SHANOOR SEERVAI: And how many people have you helped get into treatment so far?

CRYSTAL YATES: This unit started in I guess April and so far we’ve gotten, successfully gotten 89 people directly into treatment. We’re trying to bring what each person needs directly to them. I’m very proud of this AR2 unit.

SHANOOR SEERVAI: Before we end, Crystal, I wanted to talk a little bit more about you. I know that you’re the first African American woman to be promoted to the rank of Chief in the Philadelphia Fire Department. What’s that like?

CRYSTAL YATES: It’s amazing. [laughs] I’ll say that. My father retired — he was a Philadelphia firefighter. And I tell this story often: I spent a lot of time in the fire stations growing up, literally. And I never saw any women in the fire stations. I didn’t even know that it was a job that women could do. I didn’t aspire to it. It was just my dad’s job, you know?

The fire department here in Philly, I think we didn’t get our first female firefighter until 1985. So you know, that’s recent history. So imagine then coming onto a job that you never saw women working and going through promotions to become the first African American female to be promoted to the rank of Chief. It’s pretty amazing in one sense, and in another sense, it’s a little depressing that we’re still having firsts, you know, in the 2000s.

SHANOOR SEERVAI: And how do you think that this helps you to be empathetic and to understand some of the issues that the communities you work in face?

CRYSTAL YATES: I think it helps because I’m also a member of the community, that it is very important for me to remember, and to remind our workforce every time we have a new class of paramedics. We just had a class of 27 graduate a few weeks ago. I go and I talk to them before they hit the street, and the first thing I say to them is, “Listen, every person you encounter belongs to somebody. They are somebody’s mom, dad, child, cousin, best friend, everybody belongs to somebody. This job is not easy. You’re going to have hard days, people are gonna really, really test your patience. But they all belong to somebody. They are all important. And they need you at that time, regardless of whether or not we think it’s an emergency that they’re calling for, for them it’s an emergency. And I think as long as we are always looking at the people we serve as people, then we do a good job.”

SHANOOR SEERVAI: Thanks for sharing that story and thanks for being on the show with me today.

CRYSTAL YATES: Thanks for having me. It was a lot of fun.