‘Don’t leave me here, I need help!’

Gabriel had overdosed nine times before. After the 10th time, he decided that something had to change.

“I can’t do this anymore. I can’t do this anymore,” Gabriel repeated as he lay in the dirt. “I need help.”

He almost didn’t get it.

When the Spokane Fire Department’s Behavioral Response Unit (BRU) arrived on scene near High Bridge Park on the afternoon of June 26, Gabriel had already been “Narcanned” — a colloquial term to describe the process of administering naloxone to a patient who has overdosed on opioids — and brought back from the brink of death for the 10th time in his life.

Carla, an EMT from American Medical Response (AMR) loaded Gabriel into her ambulance to take him to the nearest hospital; but, as she explained his case to the two members of the BRU, he hopped out of the ambulance and took off walking back toward the park.

Carla watched him go, shouting, “And he’s gone!” to Jordan Ellinwood as she headed back to her ambulance to go to her next call. But the BRU wasn’t ready to write off Gabriel yet.

Ellinwood is one half of the BRU and licensed as a mental health counselor and mental health professional for Frontier Behavioral Health. She said Gabriel’s initial response was pretty common: a trip to the hospital can mean waiting to be treated for hours while withdrawal symptoms quickly intensify. Even those who say they want help sometimes run at the prospect of withdrawal.

In the heat of the moment, RANGE was not able to get Carla’s last name (we were only able to get her first name because it was embroidered on her uniform). We are not using Gabriel’s to protect his privacy.

Colin McEntee, a firefighter paramedic and the other half of the BRU, jogged to catch up with Gabriel. McEntee thought more could be done for him. His instincts told him that despite Gabriel’s initial exit, the man might be open to treatment options — if McEntee could just talk to him before he disappeared into the park.

A diversion is a victory

This is what the BRU does: interface with people facing psychiatric or addiction issues and help them access whatever services they need, rather than just transporting them to emergency rooms at already overflowing hospitals, or leaving people high and dry. After Mayor Lisa Brown in June declared a state of emergency in Spokane due to opioid overdoses, RANGE set up a ridealong with the BRU to see their work firsthand.

“One of our things is to get the congestion out of the ER and get people to the actual treatment they need,” said Anne Raven, Integrated Medical Services manager at SFD. Raven said even when people are supposed to be on a psychiatric hold, they will sometimes find a way to run. “The ERs don’t have enough people to watch them,” she said.

The BRU is a partnership between SFD and Frontier Behavioral Health, a Spokane-based nonprofit. When a 911 call comes in that the dispatcher tags as either an overdose or a psychiatric issue, a crisis counselor from Frontier and one of SFD’s paramedics head to the scene alongside the other first responders. That’s how Ellinwood and McEntee ended up at the same call as Carla. The BRU’s job is to address patients’ direct needs, whether that’s administering Narcan or talking them through a mental health crisis, then try to navigate them into longer-term care options, like addiction treatment, or connect them with social workers.

Every time the BRU helps a patient into more appropriate resources than the ER, they consider it a successful diversion. For Ellinwood, every diversion counts.

She tracks them on the dashboard of the BRU’s red truck, affectionately called Bertha by the team. Anytime the BRU can navigate someone into treatment, or more effective options than the ER, she adds a tally to her growing total. Since she started about two years ago, she had to add a second sheet of paper to continue marking her total, which is approaching 340. McEntee doesn’t know how many diversions he’s been a part of — the SFD paramedic on the team rotates out every six months.

While Naloxone (also known by the brand name Narcan ) brings people back from an overdose, Suboxone is used to dampen withdrawal symptoms to treat opioid addiction, and it does so without causing the sensation of being high. Naloxone gives people another shot at life, and Suboxone takes the edge off enough for the person to make a decision that isn’t quite so clouded by their craving, according to Raven.

Historically, first responders have not been allowed to administer Suboxone because it requires a medical license EMTs don’t have. Before she began overseeing the BRU, Anne Raven was a paramedic herself, and has been “slinging Narcan since the ’90s.”

“As a paramedic, there’s instant gratification of, ‘They were blue, they weren’t breathing, everybody’s looking at you, oh my gosh,’ and then it’s like, ba-boom, they’re alive! You feel fantastic about it,” Raven said, describing the experience of Narcaning a patient. “Until you go on [calls to the same person] on the next shift, and the shift after that, and the shift after that and you literally watch them die a very slow death of these repeated overdoses until someone doesn’t get to them in time. And then it’s not so rewarding anymore.”

The BRU was finally authorized to administer Suboxone in early February , though, after a year’s worth of lobbying the state from SFD’s medical director Dr. Joel Edminster.

“I’m tired of just doing the same thing every day, which is give people Narcan and then see them the next day when they overdose again,” Edminster said. “I can only smash my head against the wall and do the same thing so many times.”

In February, he finally got the approval he needed from the state Department of Health and other state medical officials for the paramedic half of the BRU to administer the drug under his medical license. Edminster is also in the process of partnering with Washington State University to study the efficacy of the program for treatment retention.

Now McEntee, the paramedic, can administer 16 milligrams of the drug on the scene after administering a test called the Clinical Opiate Withdrawal Scale (COWS), which measures the severity of withdrawal symptoms someone is experiencing. COWS measures 11 different withdrawal symptoms on a scale from 1 to 4 or 5 (depending on the symptom). McEntee can give Suboxone to anyone with a total of 7 or above, meaning a person can get treatment if they are experiencing mild withdrawals across about 60% of the symptom criteria, or more severe symptoms across two or three criteria.

The most severe possible manifestation of symptoms would score the maximum 48 points, and would need to include multiple incidents of vomiting, a pulse greater than 120, no pupil dilation, tears streaming down cheeks and tremors.

Raven told RANGE that the highest score recorded in Spokane was a 27. RANGE didn’t get an exact number for Gabriel’s COWS score, but based on what we observed and how McEntee described his symptoms, he was experiencing somewhere in the 20s — middle-of-the-range as far as withdrawals go.

Setting the threshold for administering Suboxone at 7 for the BRU was a data-driven choice, Edminster said. Other cities who have pioneered programs like this used a similarly low number with a goal of catching patients in the window of time where they are most receptive to getting help and can fully consent to receiving Suboxone and entering treatment.

According to Raven, the ability to administer Suboxone to patients on the street not only decreases the burden on ERs but increases the likelihood that a patient will get into treatment and services. If a person doesn’t have to wait in pain for hours, and can skip the ER in favor of going straight to Spokane Treatment and Recovery Services (STARS) or other recovery centers, they’re less likely to fall through the cracks.

Getting someone into treatment isn’t the end of the journey, but it’s a significant milestone: among patients who do start and continue medication assisted treatment for their addiction, the mortality rate is cut in half compared to those who don’t.

Raven compared opioid addiction to her smoking habit: “I quit a dozen times.” Eventually, one attempt stuck. Narcan keeps people alive; and, as a paramedic, Raven said she hopes it keeps patients alive long enough that they could get help or quit on their own.

With the 2018 creation of the BRU and its new ability to administer Suboxone, she’s hopeful that SFD will be more successful in helping people recover from addiction.

“I finally feel like, ‘Well, at least I’m trying something different,’” Raven said. “We’re trying to change the way we do things, because [what we were doing before] is not working.”

‘I need help!’

As McEntee caught up with Gabriel, it became clear to him that there was still a chance to navigate him through complex barriers like insurance and into treatment. As the man followed McEntee back to the BRU’s truck, he told the paramedic this was his 10th time overdosing, and that he “just can’t do it anymore.” He didn’t want to live under the bridges that stretch across High Bridge Park anymore, didn’t want to be homeless, didn’t want to be addicted to drugs.

But as he spoke, withdrawal symptoms began to set in, which typically happens within minutes of being Narcanned for regular opioid users. It started with a runny nose, and soon, Gabriel was crying as he told McEntee that he would be interested in going to a detox facility if he could get something like Suboxone or methadone — another drug used to ease withdrawal symptoms. Otherwise, he would do what he needed to do to make the symptoms go away: more fentanyl.

It was a cloudless day, with temperatures reaching 86 degrees. As McEntee and Ellinwood tried to explain treatment options, Gabriel began to take off his clothes. First, his baseball cap, then a thin red T-shirt. McEntee tried to guide him into the shade, seeing the sweat on the man’s torso. But just as quickly as Gabriel had stripped, he threw his body to the ground as he shivered uncontrollably.

“I want to be warm, put a blanket on me!” Gabriel cried, tears streaming down his face. McEntee ran to the truck grabbing a blanket and his medical kit. By the time he got back, Gabriel was writhing on the ground. McEntee draped the blanket over him, and Gabriel bit down on it hard, trying to muffle his own screams. He kicked off his oversized shoes and his bare feet scuffled against the ground as withdrawal pains overtook him.

Through his pain, Gabriel just kept repeating, “Don’t leave me here, don’t leave me!” and, “I need help!”

It was obvious to McEntee that Gabriel’s escalating symptoms gave him a high enough COWS score to be eligible to receive Suboxone, so the paramedic called Edminster, under whose license the drug is administered. Edminster gave McEntee the all-clear; he could give Gabriel a 16-milligram dose.

McEntee put the pill under Gabriel’s tongue and waited.

At first, things got worse, then the Suboxone seemed like it was starting to work. The next step would be getting Gabriel to STARS.

One of the biggest struggles for creating diversion is transport, Raven told RANGE. Because of the way Medicare and Medicaid reimbursements work for ambulance rides, there’s no money in transporting an uninsured person to treatment facilities for private EMT services like American Medical Response “the ambulances don’t want to transport them,” Raven said, “They want to transport them to the ER, because they’re guaranteed payment.”

So instead of an ambulance, Ellinwood had called STARS and asked them to send Car 50 — a partnership between the treatment center and SFD that staffs a vehicle to drive the downtown corridor and offer free transport to the treatment facility. The program, whose hours were recently extended under Mayor Lisa Brown’s declaration of emergency , gives the BRU the flexibility it needs to do what’s best for the patient. According to Ellinwood, Car 50 has taken BRU patients to STARS, to urgent care units and, sometimes, even back to their own homes.

It arrived shortly after Gabriel’s symptoms had started to improve.

When he saw Car 50 pull up, Gabriel hopped to his feet, sliding his shoes back on, and ran to the car, jumping into the back as the driver opened the door. Ellinwood followed him in, trying to talk him through paperwork about what going to STARS meant and what the Suboxone administration entailed. At STARS, there were certain expectations about behavior and by consenting to taking Suboxone, he was also consenting to being contacted by SFD’s Community Assistance Response, or CARES, team, which would stay in touch with Gabriel to keep him on track for recovery and help access additional resources.

Though his symptoms had been relieved, Gabriel still didn’t seem entirely able to listen and just kept asking to go to STARS. This frustrated Ellinwood, who wanted to make sure he had all the information he needed to understand and consent to next steps.

“He wasn’t in a spot for us to have a full conversation about the next step,” Ellinwood said. “It’s important to me, even though we have brief interactions, I don’t make promises because that’s not helpful, but I do try to do exactly what I say I’m going to, and tell people the next steps; because, in that moment, giving him the substance was going to make him feel better, and that was was he was oriented to, but he wasn’t really in the place for us to talk about the CARES referral, and the next steps, and getting involved with medication assisted treatment provider.”

Still, Ellinwood gave the driver the go ahead to take Gabriel to STARS, leaving the patient with a paper full of contact and follow-up information.

Fewer than 20 minutes later, as they drove back to the station, the BRU was dispatched to another call — this time, at the STARS facility.

It was Gabriel.

‘Because we responded.’

Almost as soon as Car 50 arrived at STARS, Gabriel’s withdrawal symptoms had dramatically worsened. He made it into the STARS building and then collapsed, squirming on the ground and screaming in pain in what looked like a seizure. An employee from STARS remarked that it was the second-worst case of withdrawal symptoms she’d seen in her time working there.

Though Suboxone typically improves withdrawal symptoms, there are some cases in which it can make them worse, or have no effect if too small of a dose is given. The former is called precipitated withdrawal , and, while rare, can be brought on by Suboxone when a patient has built up a high tolerance to opioids. The latter, protracted withdrawal , is not caused by Suboxone usage, and is simply withdrawal symptoms that peak later than expected and require a higher-than-normal dose of Suboxone to treat.

If Gabriel had not hit the peak of his withdrawal symptoms when Suboxone was administered, it’s possible not enough of the drug was given and he experienced the full weight of withdrawals 20 minutes later at STARS.

Though the BRU’s efforts on the first call had been a diversion, this time there was no other option — Gabriel needed to go to the ER.

There were still things the BRU could do for him. McEntee got permission to administer a second dose of Suboxone, this time at 8 mg, and before Gabriel had even been loaded onto the gurney, his symptoms had already started to subside.

Before the administration of Suboxone, Gabriel had been thrashing so much that Ellinwood and STARS staff feared he was having a seizure, and when EMTs from American Medical Response arrived to take him to the ER, they wanted to restrain him.

But McEntee fought for Gabriel, stating over and over that the man had not been violent, he was just in pain, and that restraints could be disorienting and disincentivize him from returning to treatment later. The EMTs assented, and McEntee rode in the ambulance with Gabriel to ensure he got to the ER safely.

As Ellinwood got back in Bertha to follow McEntee to the ER, she was clearly jarred by the experience. The BRU had administered Suboxone a few times before and it had gone smoothly each time. She’d never seen someone’s symptoms worsen. “Seeing Gabriel in the state that he was, it looked bad,” Ellinwood said. “It looked like it made him sicker.”

The experience left her feeling guilty and unsure if the BRU had done the right thing.

A couple of weeks after the call, Ellinwood’s perspective has shifted.

“Now that I know that Gabriel was in a lot of pain but medically OK, I feel a bit better about that, but I don’t think my best-case scenario is going to be the same as [McEntee’s],” she said. “As a mental health provider, I didn’t feel as happy as [McEntee] did. I never want to leave someone in a worse state than we found them.”

A few hours after McEntee dropped Gabriel at the ER, he got a call from SFD Medical Director Edminster, who approves the use of Suboxone: Gabriel was up and smiling. He’d eaten a sandwich and he still wanted to go back to STARS for treatment.

Raven told RANGE that neither she nor McEntee were sure whether Gabriel had experienced a precipitated withdrawal, which could have been caused by Suboxone, or a protracted withdrawal, which was inevitable. Either way, Raven said, Gabriel’s situation was something close to the best-case scenario.

Without the BRU, he would’ve wandered off into the woods, likely to take more fentanyl to treat his oncoming withdrawal symptoms. Because they made contact, McEntee had been able to ease the initial withdrawal symptoms; Ellinwood had helped enter him into the treatment program; and, on the second call, McEntee had been able to reverse the withdrawal and advocate for Gabriel.

Though the day she met Gabriel was a hard one for Ellinwood — and there have certainly been other hard days on the job — she knows the work is worthwhile.

Even on days like that day, when a person like Gabriel asked to go to treatment, but ended up in the ER anyway, she said, the BRU “at least made a connection. They felt like they could have a conversation, maybe be more likely to reach back out.”

It’s an emotionally taxing job, but the impact on people’s lives are real. “There are people that we’ve met that have gotten better care — or any care — because we responded,” she concluded.

Though the BRU only shows up when someone has experienced an overdose or an acute psychiatric need, Ellinwood said her patients have sometimes told her it was the best day of their week — because at least someone’s making eye contact, asking them questions and talking to them like a real person.

As for Gabriel?

He returned to STARS later that day after being discharged from the ER. Ellinwood told RANGE that he’s still in the program, nearly three weeks later, getting help for his addiction.

The post ‘Don’t leave me here, I need help!’ appeared first on RANGE Media .