"There are typical types of nights, but there is no typical night in particular. There are slow nights and busy nights, life-changing nights and throw-aways."
May 4th, 2011

Mona Hibri Paramedic

Mona Hibri is one of those wonderful people who is in her element both surfing and elbows deep in arterial spray. Currently finishing up training as a paradmedic in the wilds of San Francisco, Mona has witnessed some incredibly harrowing action. Lucky for us, she also has the story-tellers' gift for immediacy and exactitude. Because we thought Mona's thoughts and medical adventures were so telling, we're running a longer interview than we would normally. Buckle up.

Is there such a thing as a typical day for a paramedic?

The short answer is no. I also work nights, which adds another dimension to that dynamic. The long answer is that there are typical types of nights, but there is no typical night in particular. There are slow nights and busy nights, life-changing nights and throw-aways. Sometimes we’re running back-to-back calls all night, and sometimes we’re sitting at a street corner talking to hookers and pimps and various drug addicted homeless fall-out types from 3:00 to 6:00 a.m.

I’m sure you are familiar with the Martin Scorsese movie Bringing Out the Dead, and I wonder if I could refer to its depiction of a sort of surrealist mis-en-scene of the night medic. It would almost be a fabulist account of your experiences, but is there a separate psychology to the city at night?

I’m sure every medic has seen the film, and every night medic has seen it twice because it’s incredibly accurate and perfectly captures the juxtaposition of randomness that surfaces in the 9-1-1 system at night. Most of it has the ineffability of some religious phenomenon. I was once called to the scene of a resuscitation on a desolate street corner only to find a half-naked meth-addict covered in sores, lying on his side in the middle of the street, with the ashen pigment of a dead person but the strong pulse of someone sleeping soundly, completely unresponsive to my verbal, then physical attempts to rouse him. When he finally did awake after being moved, he started attacking us, screaming obscenities and derogatory names as he ran off down the street and into the night. There’s this strange loss of accountability when the sun goes down. Less law enforcement, for sure, but mostly I think it’s the absence of an audience in a high density area. The sheer fact that a homeless addict can run through the streets naked, smashing car windows, shitting on the sidewalk, harassing sex workers, and getting stabbed in the street means he probably will.

We share stories and cigarettes with sex workers, and we greet each other by name. I think I was initially surprised to find out that, yes, these people are for the most part just normal people at work, and have homes and families and responsibilities just like people who work in the day. I find myself relishing my conversations with hookers because they are incredibly honest and have an attitude of “I’ve seen it all.” Alternatively, the pimps mostly scream at each other and walk around watching their “employees,” so I stay away from them. The camaraderie works at the other end of the spectrum too. When we bring a patient into SF General at 5:00 a.m., everyone — nurses, doctors, techs, registration, janitors — have been up all night and are exhausted after fighting the chaos that ensues at the only 24-hour trauma center. They’re understanding when we appear irritated or forget a piece of patient care. Scorsese’s depiction of the overrun hospital is very similar to that of SF General: walk into Zone 1, and you see hospital beds lining the walls, each one complete with a screaming patient bleeding from the head, a rainbow of languages, psychiatric issues, and socioeconomic backgrounds.

What about your most recent shift?

My last shift was one of the slow bullshit nights that makes me fiend for even a little old lady with a laundry list of real problems. Instead the night went something like this: 40-year-old white male lying on the sidewalk outside of Walgreens. His clothes were stained and torn; his pants were unbuttoned, revealing dirty white boxers and a massive beer-belly. His hair was short and uneven, and it’s clear that another medic or nurse had given him a classic trauma-shear haircut, creating lines of shorter sections across his head, which revealed blurry tattoos underneath. The guy couldn’t walk, so we half-dragged, half-carried him onto the gurney, pushed him into the ambulance, and then spent the next five minutes babying him in his drunken state without providing any real medical care. He then urinated all over our ambulance, creating a tidal wave of piss that would migrate to the back of the ambulance on uphill streets, then upon a descent, slosh towards my dangling feet at the other end. After dropping him off at the sobering center, a place for intoxicated individuals with no other medical problems, cleaning the ambulance for an hour, and coming back onto the board, we were called to a downtown street corner only to find the same guy lying next to a shopping cart, with two black eyes and a bloody lip. Apparently, he’d left the sobering center about fifteen minutes after we dropped him off, got shit-faced drunk again, said the wrong thing to the wrong person, and got what was coming to him.

Oh my.

The failure of a medic to treat and transport someone who’s in medical need could result in being charged with neglect and abandonment, thereby stripping the medic of her medical license. So despite the fact that there was nothing wrong with this dude aside from his extreme lack of self-restraint, he was now complaining of chest pain and an incredibly specific heart condition — atrial fibrillation — and we had to take care of him as if he were innocent of manipulation. We treated him accordingly, gritting our teeth throughout, only to arrive at St. Luke’s Hospital and speak to an ER nurse who said they discharged him the day before for a similarly fantastical story. The guy was also wearing a hospital bracelet from San Francisco General dated the previous day, which means that in total he took four ambulance rides to three medical facilities and received little to no treatment because there was little to nothing wrong with him.

Is there a city program which pays for homeless or indigent ambulatory care?

Many have various health insurances, which are provided for low-income people with little to no charge by the city and state. I don’t know the specifics, but there is some limited ambulance coverage. We record patient information in our computer as much as possible, but when patients are inebriated or combative or unconscious, we sometimes have to register them with as little as “Jane Doe.” In cases with a real name or less, the patient often does not receive the bill, resulting in a loss for the ambulance company, or if the responding medic is with the fire department, a loss for the city.

There are really two separate issues here. First, many of our patients are of lower socioeconomic backgrounds and don’t have the means or education necessary to take care of their bodies, prevent unnecessary disease, and effectively manage the disorders that they have. Personally, I am grateful to be in one of the few positions that provide blind medical care to the city’s residents, regardless of financial or immigration status. In theory, EMS operates under the moral ideal that everyone deserves to live, and that the patient will receive any and all medical care necessary to ensure life, even in the absence of a means to financial compensation. In practice, this ideal is abused and manipulated by many people in the city who are often called “frequent fliers” within the medical community.

How much of your time is given to such patients?

I would guess that about a third of our patients are drunk and unconscious on the street, another third have real medical issues but don’t actually need an ambulance, and the last third have real medical issues which require paramedic supervision and treatment. That sort of brings us to the second issue, which is that most of the people who abuse the EMS system happen to be homeless or indigent. We get involved when they pass out in the street, which is honestly a police issue that is kicked to EMS; or these people call 9-1-1 desiring a variety of non-medical commodities such as a warm bed, food, opiates, and attention. All of these, with the exception of opiates, could be provided by facilities such as shelters and group homes, but for whatever reason — the immediacy of an ambulance, the extremely debilitating effects of heavy alcohol abuse, or the zero-tolerance substance abuse policy of such public institutions — they seem to prefer to call 9-1-1 and either fabricate symptoms or rattle off a list of chronic issues, which we can’t treat anyways. Such people are often construed as a burden on the city because at times of high call volume when there are no available ambulances, which probably happens daily for anywhere between ten minutes to four hours, a medic unit might be tied up treating a pseudo-patient while someone who actually needs medical attention bleeds to death on the sidewalk.

But if there is no evident medical reason for someone to be given medical treatment, can’t you simply turn them away?

Due to malpractice suits, it is incredibly risky to turn away patients who actually want to go to the hospital, especially when there are clear neurological deficits associated with alcohol intoxication and psychiatric disorders common in this subtype of patients. Once we are assigned to a call, we are legally obligated to ensure the health and safety of our patients. There is also a conservation issue at play because if we leave an intoxicated homeless person sleeping on the sidewalk, it’s very likely that another well-intentioned passerby will re-activate 9-1-1, wasting more money and resources. Ideally, we transport intoxicated people to the sobering center, but there are admission restrictions that reject any patient who is bleeding, which is not uncommon in this population of individuals. From the patients’ perspective, many refuse transport to the sobering center out of a preference for the luxury of a clean hospital bed, bed-side nurse service, and the hospital food, in stark contrast to sleeping on a waterproof mattress in a drunk-tank. The bottom line is that these people do need help. They just don’t need ours.

Have you ever saved a life?

I’ve been in the presence of a few saves, but only one has my name on it. I was the “team leader,” which means I stand back and direct the actions of the five other medics. We arrived on scene of a Chinese banquet hall in Chinatown to find an approximately 70-year-old Jane Doe not breathing and lying pulseless on the floor. Firefighters, who are usually first to respond, were already doing CPR and had defibrillated her once. I instructed the others to put her on our cardiac monitor, start an IV so we could administer medications, and place a tube down her throat into her lungs. Once she was on the monitor and two minutes of CPR had passed to circulate her blood, I looked at her EKG to see if there was an accompanying pulse. Her heart was beating rapidly, and there was no pulse in her neck, which meant that her heart was functioning electrically, yet improperly and not circulating blood. I asked my partner to defibrillate her again and to administer one milligram of epinephrine, the pharmaceutical name for adrenalin. We repeated the process according to our protocols: two minutes of CPR to circulate blood and our medication, then stop to see if our treatment had worked. It hadn’t, so I asked for another defibrillation and 300 milligrams of amiodarone, which is like a muscle relaxer for the heart’s hyperactive and electrical activity. This too failed to return her heart to its normal function, so we repeated the first step and gave her another shock and dose of epinephrine. This time, after a bit of compressions to circulate the medication, her heart started beating effectively enough to generate a pulse at her wrist, so we began to wrap up our equipment and transfer her to the hospital. We checked her blood pressure and it was ninety systolic, which means that blood was adequately going to her brain. It is extremely rare to have a return of pulse, and even more rare to have an adequate blood pressure. During transport she started to make purposeful movements, fighting the breathing tube in her mouth, which is a good indicator that she would wake up without neurological deficits. Within twenty minutes of finding her on the ground, we got her to the hospital, having actually made a difference.

Have you ever witnessed someone die?

Losing my first patient left me listless, numb, sunken, despondent, and full of existential doubt. As a nonsmoker, I was very surprised when I got off that morning and was physically compelled to buy a pack of cigarettes and chain-smoke on my roof watching the waves roll onto the beach until daybreak. Working nights means I get off work at dawn and race the sun home. It’s a surreal lifestyle that is amplified when there are negative emotions at play. It was hard, mostly because it was completely unexpected. And, again, it wasn’t my first “loss,” but it was my first time witnessing a death from start to finish.

We were called to an apartment for “shortness of breath.” I was the first one in. There was a thick layer of debris covering every surface from the front door onward. In the kitchen there were shoes on the counter, clothes all over the floor, dirty dishes piled high, and random garbage scattered about. A large woman was seated on the couch in the middle of it all, breathing fifty times a minute, with her 16-year-old and 10-year-old daughters scrambling around her in fear. The youngest immediately grabbed my leg. Her tiny body was shaking, and her eyes were wet with panic. I knelt down and asked her name and age in an effort to distract her from the horrifying sight of her mother being strapped to a chair and carried out by four strange men. “Don’t be afraid,” I said. “Your mommy is just going for a check-up. She’ll be fine.” The older daughter told us her mother had had the flu for two weeks and had been having trouble breathing intermittently, with occasional back pain for which she was taking Motrin. She’d apparently had panic attacks in the past, but had no chronic medical problems, no prescriptions, and had never been hyperventilating to such a degree. We ran tests for diabetes, cardiac, and respiratory abnormalities, and her results were normal. She would talk to us for a few seconds and slow her breathing, then disassociate, and resume hyperventilating.

We arrived at the hospital under the impression that she was having a panic attack, in tandem with the flu and her old back pain. She even got into the ER bed without our help. The ER nurses agreed with our diagnosis and were about to give her a placebo of sorts — an oxygen mask that’s not actually hooked up to an oxygen supply — to help her calm down. All of a sudden she stopped breathing entirely. At first I thought she had just stopped hyperventilating. A few moments later, her heart stopped beating. There was a rush of doctors and nurses to run the code, and different people were now doing compressions, ventilating her, starting an IV, and leading the patient care. They drew blood, and a blood gas test informed us that her blood was extremely acidic, which is exactly the opposite of what we’d expect from someone who’d been hyperventilating for a few hours. When someone is unconscious and not breathing, or breathing very slowly, acid is accumulating in the blood because there is little or no exhalation of carbon dioxide. Conversely, when someone is hyperventilating for a long period of time, they can actually blow off most of the acid in their blood and become very alkaline, or high pH. The latter is what we expected, but the reality was the opposite, which meant her condition couldn’t have a respiratory origin. The supervising MD told us that there could be a few causes, all of them environmental or drug overdoses: tricyclic antidepressant, aspirin, interferon. But she’s wasn’t prescribed anything, and we checked her blood for excess aspirin. Remembering her daughter’s statement earlier, we quickly realized that Motrin is an acid, which could be causing her abnormal blood pH. The daughter, however, failed to relay that her mom might have taken a catastrophic amount of tablets in the last seventy-two hours, which is what it would take to lower her pH so dramatically.

Though the blood is equipped with an exceptional buffering system, it is actually extremely sensitive to pH changes outside of a very narrow window. The treatment for low pH is administering a base, IV sodium bicarbonate, and basically titrating to effect. In the field, we can’t check blood pH, so we operate under the assumption of an intact blood buffering system and give one or two ampules of sodium bicarbonate to people in cardiac and respiratory arrest. In the ER, however, they measure the pH and efficacy of the bicarb. About an hour after starting CPR, and after thirteen ampules of sodium bicarbonate, the MD called time of death at 5:46 a.m. Numbers generally stick with me, but this one has been burned into the back of my brain. My boss and I requested a follow-up with the medical examiner to determine actual cause of death — whether or not it was actually a Motrin overdose — but we haven’t heard back yet.

That morning was a tough one for me; and as I sat on my roof chain-smoking and watching the ocean, I couldn’t get the 10-year-old daughter out of my head. When we wheeled her mother into San Francisco General’s ER, she was with me. I had helped her find her illuminated purple sneakers and backpack before we left her house, and I helped her find a place to wait. I said, “We’re gonna find a bed for your mommy, so just wait here for a second,” and I left her in a corner of one of the busiest ER’s in California thinking I would be back in a few minutes to bring her to the waiting room, or in to see her mom. I left her there, and her mother left her, and now her life would be changed forever.