Paramedic supervisor Alex Roehner and I are in a fly car charging down the wrong side of Nepperhan Avenue in Yonkers, New York. Alex switches between her sirens as the SUV weaves through traffic and unconcerned pedestrians.

“Two phones, four radios, a laptop, and a partridge in a pear tree,” she sighs as she fiddles with her two phones with her left hand and guides the steering wheel with her right.

Five foot ten, the 47-year-old has two studs in the left side of her nose, and a purple ribbon accents her handheld radio. (Her aura is red, she explains, but she likes purple because it’s tranquil.) Her colleagues call Alex the mom of Empress Emergency Medical Services, but Alex describes herself on her social media and dating app profiles as a “gypsy medic,” a reference to her Roma heritage.

Five years ago, Alex switched careers from “artist and drug addict,” she tells me, to emergency medical service provider. Since then, Alex has risen from emergency medical technician (EMT) to paramedic lieutenant, or “road boss.” She manages her team of paramedics and EMTs, reads patient care reports, approves Refusal of Medical Assistance requests, and drives an Empress SUV—a fly car—equipped with sirens, lights, and medical gear.

This Friday afternoon, in early November, we are headed to a nursing home in downtown Yonkers. Alex and her crew have been called to treat a “diff breather,” which is EMS-speak for someone who is having difficulty breathing. Alex grabs her purple stethoscope from the dashboard. An ambulance crew—a paramedic and an EMT—pulls into the parking lot.

The fly car is mobile and quick, allowing Alex to provide backup where needed, and, often, to get to the scene before an ambulance can. When the most critical moments of an emergency have passed and the crew has begun to transport the stabilized patients to the hospital, Alex is dispatched to the next emergency.

When we arrive at the nursing home, Alex grabs a heart monitor and another medical bag from the trunk and rushes into the building with a stretcher in tow. We keep moving as a nurse intercepts us in the hallway and tells us what she knows about the patient: he’s in the room at the end of the hallway, on the left; his blood oxygenation level is 70 percent.

Time is critical. When blood oxygen saturation falls below 90 percent, the body starts to suffocate. Soon after the drop, skin changes color and confusion sets in as the brain struggles to maintain itself without oxygen. The lungs try to compensate for the lack of oxygen by breathing faster and shallower. Within a few minutes of the first symptoms, organs fail and begin to die.

When the paramedics find the diff breather, a 68-year-old man wearing a gray beanie, he is shivering in his bed. Alex approaches.

“What’s wrong, baby?” she asks the man.

He glances at her without moving his head.

“The nurse doesn’t know how to read the machine,” he drawls, clearly disinterested.

Speaking in full, calm sentences and having an oxygen saturation of 70 percent are mutually exclusive events, paramedics know. Immediately, Alex identifies this call’s headline: in her words, “the diff breather that wasn’t.”

Alex skims the man’s medical files as she waits for the heart monitor to work. After a few minutes, the paramedics get a result. His oxygen saturation is 100 percent.

Alex places her stethoscope on his chest and hears a crackle in his lungs. Fluid buildup, she notes. Dialysis would help with that.

“Are your ankles swollen?” she asks. She gently peels the covers off his legs and laughs when she sees his feet bundled up in several layers of wool socks.

“You’re adorable, you know that?” she says. He doesn’t respond.

By now, Alex has identified the man’s symptoms and his likely diagnosis: congestive heart failure, a common condition among the elderly.

The nurse wants him to go to the hospital, so for liability reasons, the EMS staff have to take him there, even though he will miss his dialysis appointment that afternoon. He insists that the crew pack his laptop, his glasses, two cell phone chargers, and two phones in a pillowcase to take with him.

“Ready to fly, baby?” Alex smiles at the man as the team picks up the corners of the sheets to lift him and his many socks into the stretcher.

Alex sings, “I believe I can fly.”

***

In 2017, the paramedics and EMTs of Empress Ambulance Services responded to about 39,000 911 calls in Yonkers, population 200,000. Paramedics told me stories about some of their recent emergency calls: a man’s leg is broken in three places, and the train has sliced his waist; they tape his intestines and organs onto his body before moving him. A woman sobs on a bed because her husband is leaving her, an entire handle of vodka lying empty on the ground, her toddler nephew scootering around the first responders; they load her into an ambulance and head to the hospital’s psychiatric ward.

Other calls, though, are more like the diff breather: they don’t qualify as emergencies. Though EMS is built to deal with rare, unexpected medical crises, much of the staff’s time is spent responding to non-urgent calls. For paramedics like Alex, one of the most frustrating and prevalent patterns is the high volume of non-emergency calls that the 911 dispatch receives daily.

Everyone thinks what burns you out is the tragic shit: the shootings, the stabbings, the kids,” said Mike Ceriani, a paramedic supervisor and Alex’s coworker. “What burns you out are the people that you constantly pick up.

Empress employees are familiar with Yonkers’ most common 911-call subjects and their pickup addresses. “Frequent flyers”—a subset of residents who are repeatedly picked up for non-crisis situations—often come from Chicken Island and “Ground Zero,” the neighborhood with the oldest buildings in Yonkers, Alex told me.

Between jobs, in the supply room at Empress’s base, a group of EMTs and paramedics recounted to me various frivolous 911 calls they’d recently received. Ailments included: caller had a cup of coffee at 2 a.m. and couldn’t sleep; ate too many hotdogs; couldn’t sleep because the sirens of passing EMS vehicles were too loud (she had work the next day, so would they please turn it down?); had a cuticle that hurt when touched but didn’t want to pull it out because it would bleed; had a cold.

An internal study by Medstar, a large non-profit healthcare organization that handles medical emergencies, showed that 36.6 percent of their 911 calls in 2015 were non-emergencies, like “the diff breather that wasn’t.” Some Empress paramedics and EMTs estimate that non-emergencies make up closer to 40 percent of calls.

Paramedics are overqualified to be spending their days answering non-urgent calls. Alex is trained to administer over 20 different medications, ranging from narcotics to analgesics to paralytics, and she knows how each drug will interact with a patient’s other medications and pre-existing conditions. While hospital anesthesiologists are taught never to intubate patients in anything less than the best lighting conditions on an operating table, Alex knows just how to angle a breathing tube between the “V” of an unconscious patient’s vocal cords, anywhere, anytime. A paramedic’s job is to extend emergency room care into the community, wherever it is needed, and Alex is prepared to do so.

But dispatchers are obligated to send out a team, no matter the apparent degree of urgency. The “prudent layperson” standard, a law in New York and 46 other states, requires that insurance coverage be based on patients’ perceived symptoms, not their final diagnosis. Because health literacy tends to be low in Yonkers (and in the U.S.), Alex tells me, the reality of a self-report like “I have a cold” could be anything from a common cold to life-threatening pneumonia. In paramedic terms, all calls are either “bullshit” or “Oh, shit!” and deciphering between the two before arriving at the scene can be nearly impossible. In the fly car, paramedics sometimes play their own game of odds, calculating the probability of a call being legitimate based on the caller’s address and description of the situation.

In November, 911 patient transports were projected to increase by 2,415 transports between 2014 and 2017. The upward creep is bigger than Yonkers. In the past several decades, emergency personnel across the country have seen a rise in non-emergency 911 calls in urban centers, news reports say. Studies have not been able to pinpoint a singular reason for the uptick. Several factors contribute: an aging population means more elderly health problems; population growth means more health problems across the board.

In an attempt to meet rising demand, Empress is growing. Today, the private ambulance company is contracted by various municipalities and hospitals of Westchester County, New York to provide emergency medical services. Since Transcare, another local private ambulance company, declared bankruptcy in 2016, Empress has hired more than 200 new employees. On certain days, the 50 or so vehicles they put on the road still aren’t enough to handle the workload. More patients taken to the hospital means overcrowded hospitals. Doctors are busier, so paramedics and EMTs wait longer to give physicians their reports and have less time to respond to other calls—with potentially fatal consequences for needy patients.

***

On another Friday afternoon in the fall of 2017, the emergency room at Saint Joseph’s hospital is overflowing. By the circulation desk, three patients in stretchers wait to see a doctor. EMTs, paramedics, and police, who sometimes accompany drug overdose patients to the hospital, clog the narrow passageway. In curtained cubicles, patients lie in their beds and family members murmur. The doctors never stop moving between patients, like a game of human Ping-Pong.

Alex and I enter through the ambulance bay, bringing a particularly bad overdose patient to the hospital. The paramedics have injected him with 4.5 milligrams of Narcan, a drug administered to counteract the effects of opioid overdoses, and they have inflated his lungs with a manual resuscitator. Several minutes later, in the emergency room, the paramedics’ interventions finally start working. The man sits up and looks around around the room with wide eyes.

Behind him, a nurse talks to a patient at the end of the line of stretchers. It’s not obvious why he’s here. Apparently, he called the ambulance because he said he had an asthma attack. He chats cheerily with the EMS workers around him. On his right wrist, he wears a hospital wristband from three hours ago. This is his second visit of the day.

“Stay until you’re discharged next time. I hate to see you keep coming and going,” a nurse tells him.

According to the paramedic that brought him in, this man is part of a population of homeless people who call 911 for a hot meal and a bed. When a paramedic asked him why he didn’t just walk the six minutes to the emergency room, he tells the paramedic that “ambulances are the fastest mode of transportation.”

There’s a cohort of “frequent flyers” who are each picked up three to six times a day, Alex said. “We know them by name, they know us.” Repeat callers make up a significant portion of  the 36.6 percent of 911 calls that are non-emergencies, though there is no official data on their impact. Often, it’s because these individuals don’t know where else to go for healthcare and don’t have the wherewithal to follow doctors’ advice for next time.

“There’s a large part of the population that doesn’t have primary care, even though there’s been a big push for expanded healthcare and expanded Medicaid,” said Hanan Cohen, a paramedic and Empress’s director of business development. “They use the ER, which is not what they’re meant for. So there’s a lot of folks that dial 911 on a regular basis because that’s the only way they know to access healthcare.

Neither the hospitals nor Empress benefit from non-urgent 911 calls. The financial risk of taking on 911 is why many ambulance companies do patient transports only, Cohen explained. In cities where the call volume isn’t high enough to offset the costs of frivolous calls, the local government often hands out stipends to volunteer or nonprofit EMS services. Because of equipment, maintenance, and staffing costs, a basic life support ambulance costs around 400 dollars a trip, and an advanced life support ambulance costs around 900 dollars.

“In 911, our risk is, when someone calls 911, we’re going to take care of them,” Cohen said. “You don’t ask for insurance in advance. The phone rings, you ask the screening questions, and you send the appropriate resource. At the end of that, you hope that folks have a respectable enough payment method to cover some profit.”

Nationwide, approximately 35 percent of emergency-room patients are insured by Medicaid or Children’s Health Insurance Program. About 14 percent have no insurance. Empress gives away over 2 million dollars in free healthcare services to uninsured and underinsured members of the community every year.

“It’s who we are, it’s what we’ve done. And we’ve been doing it for 30-some years. Doing just non-emergency transportation—that’s a transportation service,” Cohen said. “This is an emergency medical service.”

But often, EMS transports arrive at the hospital and receive care, absent an emergency.

***

Fly car lights flaring, sirens whooping, Mike Ceriani barrels down the hilly streets of Southern Yonkers, slowing at busy intersections. (“I don’t know where the best place to stop is, but directly in front of me is not it,” he mutters.) As he swerves around oblivious pedestrians, I hold onto the grab handle above the passenger side window—the “Oh Shit” bar, in Mike’s words.

For a 31-year-old, Mike is surprisingly old-school. While most paramedics and EMTs use phone apps for directions, Mike has proudly stuck his GPS on his windshield. We listen to the Trans-Siberian Orchestra through an auxiliary cord plugged into his sixth generation iPod Classic.

Mike has been a paramedic for two and a half years. He graduated paramedic school with Alex, who occasionally refers to him as Penguin because of his baldness and his pointy nose. In his many years in EMS, including time as an EMT, he’s seen his share of overdoses, car accidents, and three-week-old corpses.

Mike and another ambulance team are on their way to treat a diabetic. Lights still spinning, we park in the curved driveway in front of an apartment building. We meet the other two paramedics, Joey and Brian, by the entrance and enter together. They cram a yellow-framed stretcher into the elevator.

When we reach the apartment on the 16th floor, the patient’s daughter anxiously ushers us in.

We find the man in his bedroom. He looks like he’s in his 50s or 60s. He hugs a navy blue pillow on a daybed and wears only underwear. Socks, shirts, and plastic wrappers are strewn on the white tile floor, though his collection of flat caps is hung neatly on a rack across his closet door.

He has been acting strangely all morning, his daughter tells us. She can’t figure out how to use his finger-stick glucose meter.

As the paramedics ask him questions, he repeats their words, not quite understanding what they are saying.

When Joey pricks the man’s finger, the meter shows that his blood sugar level is 42. A healthy person’s target sugar levels are normally between 80 and 130.

They tie a rubber band near his right elbow, slide a small catheter into the underside of his elbow, and give him dextrose. Joey holds the bag over his head, and the tube runs from the bag into his veins. He becomes more cogent after a few minutes. The paramedics try again with the questions.

“When was the last time you took your insulin?”

“Yesterday.”

His insulin is effective for 24 hours, so that wasn’t the problem.

“When was the last time you ate?”

The man thinks for a minute.

“…yesterday.”

Calls like these, from patients with chronic illnesses, are often preventable. Ideally, the diabetic would have known to eat after taking his insulin, and he and his daughter would have known how to use the finger-prick meter. They would have known that diabetes is caused by an inability to produce insulin, an enzyme that digests sugar in the blood so that the body can use it. They would have known that taking insulin and not eating meant that he was digesting more sugar than he had, which was what caused his hypoglycemia symptoms. A basic understanding of how diabetes works and how to manage it could have saved the patient a hospital bill and a trip to the emergency room.

“Folks get taken on a stretcher to the hospital, and just because they may not be well versed or very well educated, healthcare can be very confusing,” Cohen, business director of Empress, explained. “Discharge orders and follow up instructions and community resources can all be just a puzzle—a jigsaw puzzle to people. So there’s a lot of people providing post-acute care, but there’s a whole lot of folks that just fall through all the social nets or the provisions of care.”

Emergency rooms are designed to handle acute and trauma care. While doctors can tame flare-ups of chronic illnesses, long-term health problems require long-term solutions.

But lifestyle changes can be difficult. If patients return home to the same conditions and mindsets that caused the flare-up, they return to old habits, Alex told me. They make the same mistakes that brought them to the emergency room, and the cycle repeats.

In reality, Alex said, with the assistance of medical technology and pharmaceuticals, many chronic illnesses are manageable at home. Diabetes: eat regularly, take insulin regularly, know how to use a finger-stick glucose meter. Chronic obstructive pulmonary disease: don’t smoke. Congestive heart failure: eat less salt, limit fluid intake, take your medicine.

Still, many patients don’t know how to manage their diseases. When symptoms flare up, EMS staff, rather than physicians, are the ones who hear about it first.

***

Though EMS staff do their work at one of the most critical points in a patient’s recovery, they are some of the most underappreciated members of the medical community. They operate away from expensive medical equipment and sterile environments but rarely receive the same recognition as physicians and nurses.

“EMS has become the safety net for healthcare,” Cohen said. “So it’s ‘dial 911 for police, fire, or urgent healthcare’ and that’s okay.”

Unlike medical professionals treating patients in hospitals, EMS staff encounter their patients in context. They see the tangle of socioeconomic and mental health factors behind non-emergency calls. In 2017, Empress began its first foray into community paramedicine, a new program spearheaded by Cohen and Alex. The initiative will allow paramedics to schedule at-home follow-ups with discharged patients so they can teach patients and families about their conditions and how to manage them. Eventually, Cohen and Alex want patients to seek medical care that’s appropriate for their ailments at urgent care centers and doctors’ offices.

Community paramedicine will be 25 percent clinical work and 75 percent social work, Alex tells me, because the core of it is “that fish saying”: give a man a fish, and you feed him for a day; teach a man to fish, and you feed him for a lifetime. Through community paramedicine, the Empress paramedics will be able to keep an eye on consenting at-risk patients and help them adjust their lives to suit their conditions.  

Still, frivolous calls are part of the routine. It’s easy to get frustrated, but Alex’s personal philosophy helps her stay positive: the 15 to 20 minutes that the EMS staff are on the scene, she believes, is a small window to make a real impact on people’s lives.  

To Alex, EMS is about more than life and death. It’s about respect and empathy. It’s telling post-accident drivers that she “used to carry unicorn Band-Aids just for guys your size” until they smile shakily. It’s talking to the nervous son wearing a Black Sabbath t-shirt about Ozzy Osbourne as they move his bedridden father into the ambulance, or laughing with the 92-year-old Ecuadorian grandmother with pneumonia, despite the language barrier. It’s treating every 911 call with the seriousness of a life-threatening situation, no matter how trivial the caller’s complaint might seem from the outside, because, as Alex often says, “perception is reality.” She believes that’s how each 911 call should be handled, no matter which side of the 36.6 percent it falls.  

I’m not trying to change the world,” she tells me, “but you gotta have a pay it forward mindset.”