California’s EMS Providers Confront a Tsunami of Fentanyl Overdoses

Deaths from drug overdoses have increased five-fold in this country over the past two decades, totaling 106,699 deaths in 2021, and three-fifths of them attributed to fentanyl, a powerful synthetic opioid pain medication that is now rampant among street drugs.

In April, California’s Governor Gavin Newsom committed the California National Guard, Highway Patrol, and other agencies to combat fentanyl distribution in the state. His initiative includes a special partnership with the city of San Francisco, which is a ground zero for fentanyl overdoses. Protestors have objected to Mayor London Breed’s approach to addressing this challenge and tackling the city’s open-air drug markets through a unified command center and increased social services.

But what do frontline EMS providers say about the fentanyl crisis? How has the overdose epidemic impacted them?

“The fentanyl crisis has taken over how we approach everything in our jobs,” says paramedic Donnie Fisi “I can’t tell you how many times we respond to a parking lot or a bathroom at a convenience store.” He has served across San Francisco’s East Bay for 35 years but recently took a desk job as a quality assurance specialist and educator for the Alameda County Fire Department’s EMS program.

“It snuck up on us and then became a tsunami,” Fisi says. “The thing that for me is most shocking about fentanyl is how color-blind and class-blind it is. It doesn’t care if you’re homeless or if you live in a beautiful house in the suburbs. It is affecting everyone. It seems like fentanyl has just seeped into so many aspects of life. It’s so powerful. A lot of people end up not meaning to take it, not thinking they’re taking fentanyl, thinking they’re safe. It’s been cut into something they are taking and it catches them totally off guard.”

Evolving Protocols for Narcan

The opioid antagonist Narcan (naloxone), which Fisi has been using to reverse opioid overdoses since the 1970s, is now in its nasal form a regular part of the EMS responder’s repertoire. “Narcan works if you get there early enough after they’ve stopped breathing,” he explains. “But we have a very small window of time to get to them before permanent brain damage occurs, within six to eight minutes.”

In Narcan’s early days, a typical protocol was to administer a full dose to wake people right up, Fisi explains, but newer protocols give them just enough to get them breathing again.

Fisi’s longtime ambulance partner, EMT Gina Arendtson, now based in Alameda County’s Eastern suburbs, says fentanyl street overdoses aren’t as common as in West County cities like Oakland, although they still happen. But her crew is frequently called to nearby Santa Rita Jail, where fentanyl overdoses are daily occurrences. And the latest news discussed among EMS crews are about fentanyl mixed with xylazine, a powerful non-opioid animal sedative that doesn’t respond to Narcan.[i]

“Whether it’s fentanyl or any illicit substance because they usually are young, vivacious, typically men, it’s heartbreaking. You do your best, but they were just down too long,” Arendtson says. “If you have a child of your own of that same age, like I do, it really hits you. Some mother is about to get the worst phone call of her life.”

Taking a Moment

Sometimes, after a call that came too late, Arendtson gets in contact with her supervisor.

“We need a moment,” Arendtson says. “We’re going down to Starbucks to sip some tea or coffee and take that moment. Because you have to defuse the emotions from any call that really impacts you. And everybody has their Achilles heel, where it really compromises them.”

Such moments might take 45 to 60 minutes. The ambulance service emphasizes peer support, and Arendtson and Fisi have often been the peers to go and talk with another crew to help defuse their feelings.

“Hopefully, you get some resolution from it, and it doesn’t stay with you,” Arendtson says. “We do our best to put it in its proper place.”

Fentanyl deaths are particularly hard, she explains, “because it didn’t have to happen. If only we had gotten there just five minutes earlier.” The resolution comes from knowing that the crew did its best, there was nothing that could have changed the outcome, and they need to be able to move on to answer the next emergency call.

“That’s our job, but we also need to be allowed to take that moment,” Arendtson says.

A More Comprehensive System

Daniel Gerard, MS, RN, NRP, a veteran paramedic who is the EMS coordinator for an EMS service in a Bay Area city and serves as president of the International Association of EMS Chiefs (IAEMSC), says the current fentanyl epidemic is the worst substance abuse crisis he has seen in his entire career.

“I was an EMT in Newark, N.J., and it’s not like ODs are something new for me,” says Gerard. “But with regard to all the ODing in public places, in grocery store restrooms, we’ve seen a 60 percent increase in the number of overdoses over the last four or five years. It’s upsetting for a slew of reasons, and it still shakes me to the bone, even though I’ve been in EMS since 1981.”

Part of the problem is that there is a treatment—Narcan—but Narcan is not a therapy for curing opioid abuse.

“Plenty of people die with Narcan in their pockets,” he explains.

For Gerard, the answer lies in a more coordinated, comprehensive system of emergency services for the opioid crisis.

“When we talk about trauma or cardiac arrest and emergency services, we’ve done fantastic work in recent years in coordinating all the services needed,” he says. “But we’re still dancing around implementing a similar system of care for drug overdoses.”

Many professionals and administrators still refuse to accept that drug abuse is not a moral failure

but a disease.

A more comprehensive system would use California’s network of bridge hospitals, which are qualified to provide advanced addiction treatment and increase the use of community paramedics and crisis mobile response teams.

“Let’s go out every day and offer medication-assisted therapies for opioid use disorder—suboxone (a combination of buprenorphine and naloxone), or methadone,” he encourages. “Let’s help these people get into facilities. Then we could offer housing and other social supports. There are a bunch of options we could leverage with a 360-degree approach.”

Gerard’s idea could also include virtual safe injection sites using apps, distribution of drug test strips, and wider dissemination of Narcan.

“We’re not talking about a whole new level of care but better coordination of existing services,” he explains. “Maybe then there’d be fewer patients falling through the cracks.”

Such a system would also require the involvement of all interested parties in the planning—including hospitals, substance abuse experts, rehab and detox centers, mental health services, local EMS organizations, and public health departments.

“Everybody has to be on board,” Gerard says.

Burnout Continues to Grow

“You have a job where you just see the worst that can happen in society. It’s tough to be exposed to that for so long,” Fisi says. According to him, burnout is common.

“We come to work out of devotion,” he says. “When you’re a paramedic, an EMT, it’s a calling—almost like the priesthood. But it is burning out our workforce. We’re running paramedics into the ground.”

And while fentanyl is not the direct cause of that, “on top of the fact that we’ve just come out of the COVID pandemic, and now we have to handle the fentanyl crisis,” explains Fisi. “It’s just a lot to try to deal with.”

Because of the nature of the fentanyl epidemic, it’s easy to feel that this person is never going to get better, he adds. “What leads to burnout is knowing that we’re just a temporary fix. You can save them and the next day or, in some cases, a few hours later, you’ll be back,” he says. “Now, more than ever, paramedics and EMTs see ourselves as soldiers in a war. There are lots of casualties. We see them every day and it takes a toll. We’re tired.” Regardless, EMS providers continue to look for ways to combat burnout and provide better services for the fentanyl epidemic.

“I do want the public to know that no matter how discouraging it is, we’re going to be there,” says Fisi. “When you call, we’re always going to respond. We won’t let you down.”

What You Should Know About Xylazine. Centers for Disease Control and Prevention.