Detroit — James Davis is speeding behind Detroit Fire Engine 44 to a west side motel for a cardiac arrest run. When he arrives, the outcome already seems clear.
"He's ice cold," said Davis, chief of the department's 8th Battalion, after firefighters entered an upper-level room at the Bali Motel off Eight Mile to assess a fully dressed man lying on the floor with drug paraphernalia nearby.
The team begins compressing his chest and administers a nasal form of Narcan, an emergency treatment for suspected opioid overdoses. An EMS crew arrives and takes over, but Davis said it's too late.
"They have enough knowledge and skill to know this guy is gone," he said of the man that Detroit police on the scene confirm is from Hazel Park. "There's no reviving him."
This scenario that played out in July has become the daily reality for Detroit's Fire Department since its firefighters have become cross-trained to administer emergency medical care, which now dominates the runs of many city fire companies amid an escalating opioid crisis.
The problem has gotten so bad that on one occasion, Davis noted, firefighters treated the same woman twice in the same day who had overdosed in two different locations.
The Detroit News conducted a series of interviews and went along on all-access emergency runs with Detroit firefighters between July and October to better understand the daily pressures placed on the department.
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Among them is the Medical First Responder program put in place in 2014. Before then, Detroit was one of the only major fire departments in the country without cross-trained firefighters. Detroit has 33 medical first responder companies, with the last going live in 2017 after a two-and-a-half year transition.
The city's fire and EMS crews responded to 145,027 emergency medical calls in 2018 in a rapidly growing area of their responsibility. In 2017, they were deployed to 141,157 emergency medical calls. In 2016, they responded to 138,117 medical runs along with Detroit EMS.
The new role has some firefighters "mentally tapped out," said Detroit Fire Fighter Association President Mike Nevin.
"You are going from reverse to drive without any neutral. We go from a Narcan overdose to a dwelling fire and a rescue possibly, to a shooting,” Nevin said. “We’re playing doctor and firefighter back and forth in a city that’s undermanned, understaffed and running like crazy.”
Nevin said the department's current force of 821 firefighters should be closer to 1,000, and it needs more EMS rigs and fire companies in service.
"I did six runs with EMS today already," Nevin told The News after an eight-hour ride with Medic 14 and Engine 41 on the city's east side last summer. The runs took place within a five-hour span.
"They are out again now. They got a run for another overdose."
The number of opioid-related deaths in Detroit has climbed from 46 in 2012 to 280 in 2017, according to the Michigan Department of Health and Human Services.
Joneigh S. Khaldun, Detroit's health director, said many of the deaths are associated with synthetic drugs, including fentanyl and carfentanil, which are more potent than drugs such as heroin.
"What we're seeing is consistent with what's going on across the country," she said. "More and more opioids are being laced with fentanyl and carfentanil."
In 2016, Detroit's overdoses accounted for nearly 40 percent of the 538 opioid-related deaths in Wayne County. In total, 1,786 Michigan residents died that year from opioid overdoses, state figures show.
"The fact of the matter is the number of deaths continues to increase," said Khaldun, who said fighting the crisis is a top priority of her office. "While the number of opioid overdoses has increased significantly across the country, the issue of substance use disorders broadly has been a challenge in urban environments for quite some time."
The state in October reported a new record: 1,941 of the 2,729 overdose deaths in 2017 were opioid-related. Figures for 2018 are not yet available.
Detroit's addition of medical first responder responsibilities for its fire department "happened to come right in the middle of the escalation of the crisis," said Dr. William Fales, state medical director for EMS and trauma for Michigan's Bureau of EMS, Trauma & Preparedness.
"They kind of got a baptism by fire of having to deal with critically ill (overdose) patients that are not breathing," he said.
Statewide, there was an 83.3 percent increase in EMS-administered naloxone, a medication best known as Narcan that is used to block the effects of opioids, over a six-year period ending in 2018, according to state data. EMS data also shows that 24 percent of Michigan counties have doubled use of the life-saving medication from 2012 to 2018.
In Wayne County, the administration of naloxone increased by 231 percent in five years — between 2012 to 2017 — and it went up 32 percent in Oakland County and 77 percent in Macomb County.
Nationally, about 85 to 90 percent of fire department responses are now medical, said Ed Conlin, division director for emergency response and responder safety with the National Fire Protection Association.
"Fire departments have become more of an all-hazards response," he said. "It's been steadily increasing."
For Davis' crew, drug overdose runs have become the norm.
"We may use seven to eight Narcans a day. Just in my battalion, easily," said Davis, adding each fire company in Detroit is issued two doses of Narcan apiece but can pick up more, as needed, with proper documentation of where and when it was used.
In 2018, 2,873 doses of Narcan were administered in the city, according to fire department data.
'He was dead'
At the Bali Motel in July, maintenance worker Donald Carlson stood by as medical personnel worked on the overdose victim that he'd found unresponsive in the room that morning after the man failed to check out at 11 a.m.
"I knew right away he was dead," said Carlson, watching from the second-floor balcony as the fire and EMS crew carried the man out of the room and down the stairs to an ambulance waiting on Eight Mile. "There was a spoon right by his head on the table. Someone came up yesterday and pounded on the door and sold him something."
It was unclear how long the man had been down. Typically, Davis said, the people supplying the drugs have been alerting firefighters of overdoses to get quick aid.
"Nine times out of 10, the person selling the drugs will bring that person to the fire station and drop them off," Davis said. "Because this guy is in a hotel room and doesn't have to check out until 11 a.m., we have no way of knowing. But just from the signs that he physically had tells us he's been out for a while."
Later that same day, the engine from Davis' firehouse pulled up at a vacant house on the west side for a second overdose situation.
In that case, a male victim was lying on the floor of the kitchen with garbage strewn all over. He was given two separate rounds of Narcan and chest compressions. After a few minutes, he woke up and made it back outside to the porch. He refused further treatment.
Matthew Ponce, a Detroit firefighter out of Davis' west side firehouse, said Narcan can take five to 10 minutes to kick in and binds to the opiate receptor in the brain. Once 2 milligrams are administered, it stays in the system for 20 to 25 minutes, he said.
"The increase of Narcan is going up and up," Ponce said. "It all starts at the top and ends at the bottom once these people get addicted to the opioid."
Fire Capt. Dexter Dixon was among the firefighters with Davis who attempted to administer life-saving care to the victim at the motel that morning.
The team stood by as the EMS crew took over to continue working on the man in the rig. Dixon tried to cut the somber mood, telling Davis: "Hey chief, I got new shoes."
Davis responded: "I saw that. They're cute."
"See, we laugh and joke? We have to," Davis told The News. "These young guys that come out of the academy, they don't know. Even guys that transfer from other departments to the city of Detroit, they are not prepared for this."
Khaldun said the city's health department has revved up its efforts to address the opioid epidemic over the past two years.
Goals of addressing the epidemic, she said, are prevention, expanding access to treatment and life-saving naloxone.
In Detroit, the health department has 1,000 naloxone kits and, with a $2 million federal grant from the Substance Abuse and Mental Health Services Administration, intends to train 4,000 community partners over the next several years to administer it. Khaldun said the naloxone distribution program is the first of its kind for the Detroit Health Department and will begin ramping up by early spring.
With help from the Michigan Health Endowment Fund, the health office has developed an educational campaign they expect to launch this year to address stigma and connect people to mental health and substance use disorder resources. A pilot program is also being developed that would link overdose patients in emergency departments with immediate treatment, she said.
Michigan in 2017 issued a standing order to pre-approve pharmacists so they could distribute naloxone to those at risk of an opioid-related overdose. The order also covered family members, friends and others who might help a person at risk of overdose.
More than 60 percent of Michigan pharmacies have registered to dispense naloxone since the state order.
Detroit's health office has been working with pharmacies to support them in expanding access to naloxone. Having the firefighters trained as first responders aids in the battle, Khaldun said.
"It's incredibly important," she said. "Anyone who is a first-responder should be carrying naloxone."
Detroit Fire Capt. Keith Martin was with Engine 55, a west side company near Joy and Southfield, when the first responder runs began. The firehouse, he said, quickly became one of Detroit's busiest.
"It was a culture shock for us," said Martin, of the 4th Battalion on the west side, during an interview at the firehouse on Curtis off of the Southfield Freeway. "You know it's coming, but when you're actually doing it day in and day out, you're exposed to the stuff you see out in the field. It's hard."
Nevin said he's advocated for a peer support team to assist firefighters with the added stresses of the job.
"We’ve dealt with the car accidents. We’ve dealt with the burns, and we’ve dealt with just the stresses of going into a burning building. Not too many people chose to do that for a profession," he said. "What you are asking your mind and heart to do is switch gears too fast. There's only so much you can handle."
Suiting up with body armor
Detroit Fire Commissioner Eric Jones said the department has a Personal Guidance Unit and chaplains available to aid firefighters in coping with the trauma of the job. He said there's also a committee working to expand other peer support programs.
The medical first responder designation also has landed Detroit’s firefighters at active scenes along with the city’s police force, putting them on the front lines of shootings, stabbings and domestic violence.
To combat the dangers, Jones said the city is outfitting members with protective body armor. Jones said the department has purchased 1,200 vests and is aiming to distribute them by the end of the first quarter of 2019.
“Our firefighters are going on the same runs that our police officers are going on. They are staging for shootings, stabbings, whatever the case may be, so we want to give them as much protection as possible," Jones said. "It's the world we live in."
The day Jones took over as commissioner of the fire department in October 2015, two Emergency Medical Technicians came under attack by a man wielding a razor-sharp object as they helped a woman. The pair were slashed in the hands and face and suffered serious injuries.
"This is the first time in the history of the Detroit Fire Department that the members, other than arson, are wearing body armor. It's just common sense," Jones said. "There's been shots fired on runs that they've been on and thank God we haven't had any injuries of our members."
Detroit Fire Department Sgt. Randy Jones said firefighters can't prepare for the emotional toll of medical runs.
"To actually prepare yourself mentally for a medical run, it's impossible. It's the same as saying 'I'm preparing myself to face death,'" he said. "You are going to face it. It's coming at you. There's nothing you can do to stop it."
The 26-year veteran of the department said "we're used to fighting fires" and the transition has been a challenge.
"You just rehab yourself afterward. I pray," he said.
On a Saturday in October, Randy Jones stood outside a west side home that had called in a suspected carbon monoxide leak. The fire crew detected unsafe levels in the kitchen and called in a hazmat crew to assist.
As Jones waited, a call came over the radio: Code 1 for EMS, a 40-year-old male was having a seizure.
"Those are the medical runs," he said. "They just keep coming."
Minutes earlier, it was a call for aid involving a child with asthma.
"Those are the worst runs. Any time you get kids," said Jones, noting the death of a child the week prior. "I chose this job to help people. Do I feel that I'm helping people? Yeah, I do. So I go home, I kiss my grandkids, and I just keep moving."
East side fire chief Charles Gerardy of the 9th Battalion has been on the job for more than three decades. In his east side district, the medical runs are worse than fires and he expects over time they will take a dramatic toll.
“Mentally, these guys are seeing dead people two times a day now,” he said. “In five years, who knows how they are going to be.”