Why Does the Richest Country in the World Rely on Volunteers for Emergency Healthcare?
“I’m the smoker.” Brody, an elderly gentleman who answered the door, spoke matter-of-factly. I had been surprised to find the air in the apartment so oppressive; I was wearing an N95 mask, eye goggles, and face shield, in addition to my EMT turnout gear for contact protection, a head covering, and gloves. The N95 mask filters out smell. But I could smell this apartment. And judging by the smell alone, I was in an ashtray.
The call was for a 64-year-old woman with a cough and inability to walk. Because the patient had a cough, one of the symptoms of COVID-19, the call had been dispatched as “infectious disease.” In keeping with our fire company’s COVID-19 procedures, I’d gone alone into the apartment with my radio and a bag of medical equipment. I would radio to my partner, Talia, the ambulance’s driver, if I needed anything.
The patient was Brody’s partner, Helen. Brody, a spindly man with a thatch of white hair, led me through a cluttered living room into a bedroom, where Helen sat on a bench at the foot of the bed. She wore a lavender t-shirt and panties. Her bare legs were excessively swollen: she’d lost definition around her knees, and she had rolls of skin over her ankles.
I greeted Helen, introduced myself, placed a pulse oximeter on her finger, and took her temperature with a temporal thermometer. She didn’t have a fever.
“In the last two weeks, have you had any fever, cough, or shortness of breath?” I asked.
Helen nodded. “I have a dry cough.”
“How long have you had it?”
“Three weeks. I get bronchitis,” Helen explained.
“Is that normal for you?” I asked.
“Yes. I get bronchitis a lot.”
“Do you have chronic obstructive pulmonary disease?” Chronic bronchitis, along with emphysema, can be the basis of a diagnosis of chronic obstructive pulmonary disease. The illness is most common among smokers, but second-hand smoke is also dangerous, and living in this apartment cannot have promoted optimum pulmonary health for Helen.
“No,” Brody interjected. “I’m the smoker. She’s the drinker.”
“I haven’t had a drink since October 23, 2018,” Helen recited proudly.
“That’s wonderful,” I replied. I looked at the pulse oximeter screen, which showed Helen’s heart rate and blood oxygen saturation. Both were normal. “Have you been staying at home for the past three weeks?”
Helen nodded. “I can’t walk.”
The career EMT’s were getting hazard pay. We volunteers weren’t. So why were we putting our lives on the line?
While Helen had a cough, her history of chronic bronchitis and the smoky environment in which she lived suggested that it might be a non-COVID cough. Her lack of fever and normal blood oxygen saturation, along with the fact that she had not left the house in three weeks, likewise supported my assessment that she likely did not have COVID-19.
But she did not appear to be having a medical emergency. I was confused about why 911 had been called. “Do you want to go to the hospital, Helen?”
“I’m sorry to have called 911,” Brody answered. “I just can’t manage her anymore.”
I asked Brody for more details. In addition to her regular bouts of bronchitis, Helen had cirrhosis from her alcohol use disorder and lymphedema, a condition that results when lymph nodes are unable to drain lymph fluid, with resulting fluid retention in limbs—in Helen’s case, her legs. She had also developed urinary incontinence with her most recent bout of coughing. For the last three weeks, every time she coughed, she involuntarily urinated.
Brody had been managing the situation by changing her frequently and using menstrual pads in her underwear. But Brody weighed less than Helen, and Helen’s immobility compounded his difficulty lifting, changing, and otherwise assisting her. After three weeks, Brody was exhausted. He wanted Helen to go to the hospital to receive care for her incontinence.
“Do you want to go to the hospital for your involuntary urination, Helen?” I asked. “You know that there’s a risk of contracting COVID-19 at the hospital.”
She nodded. “I’ll go.”
As an EMT, I take patients to the hospital if they want to go. I do not pass judgment on the severity of their health conditions or whether their use of the health care system is appropriate. In Helen’s case, I did not judge whether it was wise for her to go to the hospital, where she might be exposed to COVID-19, and where the help that could be provided might be minimal.
But I understood that, in all likelihood, taking Helen to the hospital would be futile. Brody openly articulated that he had called 911 because he’d needed a break as a caregiver. His situation is far from unusual; many families care for loved ones who are physically or mentally ill or disabled. If these loved ones had home health aides, or lived in institutional facilities, they would receive care from professionals on their full- or part-time schedules. But family caregivers are on duty 24/7. Ideally, Brody would have been able to access healthcare support for Helen in their home. Such a solution might have prevented him from becoming exhausted and protected Helen from being exposed to COVID-19 in the hospital.
Unlike firefighting, no volunteer EMT signs up with the idea that the work could be potentially fatal. The pandemic required volunteers to step up to a scale of risk for which no one was prepared.
Brody also called 911 because he’d hoped the doctors could solve Helen’s incontinence, so that she would be able to return home without requiring him to provide such intense and regular caregiving. But urinary incontinence may not be a problem that can be solved for Helen in our health system. Alleviating her incontinence likely requires a holistic approach. For example, Helen’s living environment is thick with second-hand smoke that causes her to cough, which provokes her involuntary urination. One intervention that might help her incontinence would be a change in Brody’s smoking habits. Either he could smoke outside or reduce or quit his smoking. Another conceivable intervention might be better ventilation for their apartment.
Similarly, the type of incontinence Helen experiences is often first medically managed with lifestyle changes, like bladder training, pelvic floor exercises, and a schedule for fluid intake. Based on what I witnessed, Helen and Brody are unlikely to be able to implement these kinds of initiatives without assistance.
Even if Helen’s incontinence was not remediable through lifestyle changes, and was best managed with a surgical solution, it is not clear that she would be a candidate for surgery. She is a complex patient with multiple underlying health conditions, including cirrhosis, which can cause bleeding and decrease the ability of the blood to clot. Cirrhosis can also predispose patients to infection, impair kidney function, and decrease tolerance for medications that are metabolized in the liver. All these conditions can increase the risks of surgery and render the cost-benefit analysis of an elective surgery to treat incontinence unfavorable. Besides which, in the midst of the COVID-19 pandemic, all elective procedures had been canceled.
Our health system writ large is simply not set up to support the best health possible for Helen and people like her. Rather, by design, it produces exactly the outcome that resulted in this case: a transport to the hospital with definite risk and unclear benefit.
I radioed to Talia to bring a stair chair into the apartment, which was on the third floor. The apartment building had no elevator. Talia and I changed Helen’s underwear and gave her a fresh menstrual pad to absorb any additional urine. We helped Helen put on sweatpants and assisted her into the stair chair. Then we carried her in the stair chair down the stairs to the stretcher waiting at the apartment building’s entrance.
Two days later I received a call from the EMS Supervisor to alert me that Helen had tested positive for COVID-19.
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Right now, hundreds of thousands of people in the US volunteer to respond to emergencies in their communities. The number of volunteer emergency medical responders is not known, but it can be estimated to be in the six figures. Many of the 745,000 volunteer firefighters counted by the National Fire Protection Association are also EMT’s or paramedics, and many of the more than 260,000 professional EMT’s and paramedics tallied by the Bureau of Labor Statistics also volunteer their time. For example, at my fire company, the majority of volunteer firefighters are also EMT’s or paramedics, and many of those volunteers with EMT qualifications also earn money as EMT’s.
All told, volunteers provide emergency medical services to at least a third of the US population—more than a hundred million people.
That volunteers in so many communities throughout the nation organize themselves to meet the emergency response needs of their neighbors is partially a reflection of our culture’s veneration of self-reliance. We don’t have a national health system. We don’t have national unemployment insurance, basic universal income, or free universities. But we nonetheless generally accept that no one suffering a medical emergency should be unable to get to the hospital. In the context of our toleration for people suffering all kinds of other exigencies (especially impoverishment and race-based discrimination), this consensus strikes me as remarkable.
It’s all the more extraordinary because no such consensus exists about access to the healthcare system once the ambulance has transported the patient to the hospital. Disparities in the delivery of healthcare are legion. Race, gender, domicile status, socio-economics, history of substance-use disorder, mental illness diagnosis, incarceration status, age, and location all influence the quality of care patients receive in hospitals. Moreover, for those without private insurance, Medicaid, or Medicare—and even for those who have such coverage—corporatized hospitals may lack the “service to all” ethos that characterizes government-run EMS operations.
The fact that universal emergency medical services have gained traction, when provision of other needed universal services has not, may relate to the origins of EMS. Ambulance- (and helicopter-) based emergency medical services are the offspring of combat injuries and motor vehicle accidents. Civilian emergency medical services arose from the connection of service lines devised by militaries to deliver medical treatment to their wounded with the traumatic injuries resulting from vehicular travel on highways. During the Vietnam years, the logistical question of what to do with our wounded on the sides of roads was answered with a military solution, and the modern era of EMS was born.
That Americans can rally around services that sprung from our love for the military and cars, however, does not mean that state and county governments are willing to pay for such services, and in a huge swath of the US, they don’t. More than 95 per cent of the land area in the US is rural and home to some 60 million people. In these areas, for the most part, government does not pay for any emergency medical services. In the rest of the country, payment for these services may be below what is needed. These shortfalls are covered by volunteers.
For my part, I have found many of my chosen family in my fire company.
The fragility of this system cannot be overstated. Volunteer fire companies rely on fund raising to operate. Among the incongruities of the COVID-19 pandemic is that, just when emergency medical services are needed most, fund raising has become inordinately difficult. Many fire companies rely on interactions with the public to raise money. At my fire company, we host birthday parties and stand on traffic islands with our boots, asking passing drivers to please “fill the boot” with money. These activities are not compatible with quarantine and social distancing guidance.
Unlike firefighting, no volunteer EMT signs up with the idea that the work could be potentially fatal. The pandemic required volunteers to step up to a scale of risk for which no one was prepared. Moreover, some volunteer EMT’s are over 60 or have underlying health conditions that make the exposures to patients who might have COVID-19 too risky for themselves. For other volunteers, their concern is the possibility that they could transmit the virus to their families. Many volunteers were also prohibited to volunteer (or strongly discouraged) by their full-time employers.
Our county additionally presents the odd situation of having a mixed volunteer and career emergency response system. My volunteer fire company does exactly the same work as the career fire company down the street, but the emergency responders at the career stations cost the county millions of taxpayer dollars, while we donate our labor to the community. The career EMT’s were getting hazard pay. We volunteers weren’t. So why were we putting our lives on the line?
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Emergency response volunteering runs in families. The captain of my fire company is the son of a volunteer EMT. Cap’s youngest brother, Slim, was the captain of another nearby volunteer fire company, and their middle brother, Luke, is a Lieutenant for the aerial tower truck at our fire company. One of the former captains of our fire company, Gil, is married to the current president of our fire company, Sandra, and their son, Noah, is one of the youngest members of our company.
Not all these family connections are blood relatives, however; some are chosen family. Wesley, who is a year or so older than Noah, has been finding chosen fathers at our fire company for years. One of our fire company’s former captains, Jerry, considered Wesley to be like a son. Only in his fifties, Jerry died of cancer recently, and afterwards, Wesley moved into our fire station. Many of the firefighters, but especially Rocky (a retired career firefighter whose uncle had been a captain of our fire company decades ago), parent him. For my part, I have found many of my chosen family in my fire company. Of especial importance is Talia, my frequent partner on ambulance shifts, who is like a younger sister, and Dr. Shai Elias, a county fire surgeon (one of the physicians who supervise the EMT’s), who is a mentor, friend, and frequent host, inviting me to holidays and to stay whenever I am in town.
While the quarantine occasioned by the COVID-19 pandemic persisted, I found my volunteering had new urgency and meaning, not just as an EMT, but as a family member in my chosen family. In particular, my energies went to Torkom and Milena, an older couple who are refugees from Iraq. I’d met them when I was volunteering for the International Rescue Committee, before I went to medical school. IRC assigned me to be a “family mentor” to Torkom and Milena, and I volunteered to become their kin.
Ethnically Armenian Christians, their home had been in Baghdad. Torkom had spent his career as a mechanic working on Caterpillar machines; Milena had been a tailor. They have three children, two sons and a daughter. One of their sons died in the Iran-Iraq War, in the 1980s. Over the course of US military action in Iraq, Torkom, Milena, and their son, Tigran, and daughter, Anahit, fled Baghdad. Devastatingly, the family was separated: Torkom and Milena received asylum in the United States, while Tigran and Anahit and their families were settled in Germany and Canada respectively.
Speaking just a few words of English, Torkom was over 80 years old, and Milena was about ten years his junior. For two years, I visited them every week. Torkom always made sweet Arabic coffee that he served in demitasse cups and proffered dates for me to eat. Torkom was exuberant about his love for me: “Maya, you my girl!” he would shout, smiling, every time I arrived or left.
Another Iraqi refugee, Sami, sometimes translated for us. Sami and his family had also lived in Baghdad. Sami had been injured in an explosion that had left him blind and with a prosthetic arm. Smart and resourceful, Sami was working on his GED, even though he was in his thirties. His only quality that might have been greater than his resilience was his kindness—he always spoke gently, was always willing to help, and was always ready to share a laugh.
When I had gone to medical school, I knew Torkom and Milena felt the loss, but I felt helpless to do anything about it. I visited them whenever I returned. Milena spoke about as many words of French as she spoke of English, but I think she preferred to use French words. “Milena pleure,” she would say to me, when I was leaving one of these visits. She didn’t just speak the words; she also cried.
Then, in March my medical school suspended our hospital rotations because of the pandemic. I returned to my fire company to staff the ambulance and, by chance, I was staying close by to Torkom and Milena’s apartment. I called Sami to ask after them. Did they need any help? Could I do their grocery shopping?
Sami called me back after he’d spoken to them. They did not need grocery shopping—Torkom proudly walked to the nearby grocery store regularly. Although he was in the age range that made him vulnerable to a difficult course of COVID-19 if he contracted it, Torkom is headstrong and independent, and he could not be persuaded to let me do his grocery shopping. However, Sami told me, Torkom did need some masks and gloves because he insisted on going to the grocery store.
The next day, I drove the short distance to Torkom and Milena’s apartment. I donned an N95 mask and a pair of nitrile gloves. I had put another N95 mask and many pairs of gloves in a bag for Torkom, and I left them at the entrance of the apartment building. Then I stood back six feet.
I had emphasized to Sami how he must instruct Torkom not to come within six feet of me or to try to hug me. Still, I was worried. Being headstrong and independent, Torkom followed his heart and did what he pleased.
But today, Torkom’s heart counseled him to be safe. He opened the apartment building door and stood in the sunshine wearing a surgical mask and gloves. Not even the mask could hide the fact that he was beaming. “Maya, you my girl!” he shouted, waving at me from the doorway. He bent down to pick up the bag I’d left. “Thank you! Thank you!” he exclaimed when he stood. Then he pointed over to the basement window.
Peering through the window, I saw the living room of Torkom and Milena’s apartment, and Milena supporting herself against the wall. “Maya!” she cried, when I came into view. “Ça va bien?”
“Ça va bien,” I assured her. “Et tu?”
“Bonne,” she replied.
“Je t’aime,” I called.
Her face opened into a broad smile. “Je t’aime,” she reciprocated.
I waved both my hands, to Torkom standing in the doorway, and to Milena through the basement window.
I retreated to my car and sat behind the steering wheel. I felt stunned by how much I loved them, and by how much pain I felt being physically proximate, and yet unable to hug them, or share space with them. I realized that my heart, as well as my life, was on the line during this pandemic: I had volunteered to put them there.
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Out of consideration for the privacy of the patients, and the company’s members, all efforts have been made to preserve the anonymity of the company. If you want to contribute financially to support Alexandri’s volunteer fire company’s operations during the Covid-19 pandemic, you may do so at this GoFundMe site. We appreciate that financial contribution is not within everyone’s means in this trying time, and we are grateful for any expressions of generosity, be they words of encouragement, good intentions, or your prayers.
