The first thing I register is the officer’s words as he gives report to my partner. “…hasn’t taken meds in six months…hasn’t been out of the apartment in six months…hasn’t eaten in three weeks…” The officer continues to fill in the blanks, that she lives with a roommate but that he is bipolar and hadn’t thought these things were concerning. The report complete, my partner and I enter the residence.

The second thing I register is the haze. I’m no stranger to odors but as we walk into the apartment, my lungs physically rebel at roughly the one minute mark. The apartment is literally foggy with acrid, dense cigarette smoke. I follow my partner’s grey shirt in front of me, sizing up our surroundings as we advance. I register a synthetic “feather” duster on the stove, between the electric burner and a frying pan, but the light indicating a hot stovetop isn’t lit. The duster isn’t smoldering, and so I continue towards the back bedroom, entering just after my partner. I’m already coughing, thanks to the lung issues I’ve been slowly coming to terms with. Last December my primary care provider tells me my seventeen years of smoking have had some impact on me even now, six years after smoking cessation. Each room we’ve passed now, in this apartment, has had at least one overflowing ashtray and my lungs are registering the effects.

I can see the patient over my partner’s shoulder. There is a plethora of belongings and in the bed a fully dressed female, frail and nearing emaciated. She is older than myself but of indeterminate age beyond that. More ashtrays are heaped and packs of cigarettes, of the empty crumpled kind and one full pack, ring the bed. The fingernails and toenails of my patient are long, curved, and black with an unknown substance. On the floor next to my boot, two flat dried dark substances that may be mud but which my mind tells me are not mud. The patient’s hair is dark with white chunks. I look harder thru the fog, my face squinting up with effort. The white chunks are accumulations of dead skin, scalp tissue.

At this point, my lungs aren’t kidding around, I register honest pain. They hurt, and the coughing seems to be drawing the fog deeper into my lungs between barks. I move into action now, encouraging the patient to swing her feet to the floor, to sit on the edge of the bed, to stand up. We do these things slowly but with purpose, letting her get her bearings, letting us evaluate her for steady gait, etc. She ambulates to the middle of the kitchen with copious encouragement but that is as far as she can or will ambulate. I ask if my partner would like the stair chair, and when he nods, I flee to the corridor in relief. The officer remains at the doorway, holding the door open. Some of the fog has leaked into the hallway but it is still infinitely clearer out there than in the apartment. I place my hands on my knees and bark the deep kind of cough, the kind that hurts and makes others uncomfortable. I do this for a bit, sucking in the sweet air. The officer asks if I’m ok, then kindly tells me, “I’ve seen worse”. I don’t tell him so have I, or that I’ve come to know personally, much as some of my patients have learned the hard way – smoking is the gift that never stops giving. I just nod, and after the barking subsides, I walk outside, gulping beautiful outside summer air, and return with the stair chair.

The apartment is just as I left it, with one exception. The roommate is hovering in a helpful manner near my partner and the patient, who is now seated on a kitchen chair. As he hovers, the roommate is also smoking a fresh cigarette. I set the stair chair down and pull the red levers which drop the seat, and the tracks. Except the seat refuses to descend. Resolutely, the sweat now running down my neck from the heated, close apartment air, I try again, and again. Same refusal of mechanism. My partner tries and on his fourth attempt, the seat meekly drops open. I maneuver the chair behind the patient, encourage her slow standing and reseating, then fasten the belts and make my second escape to the hallway with her in the stair chair in tow. I bark some more. The officer tells me kindly “you’ll get used to it eventually” and again, I nod with a smile.

Driving down the street a few moments later, I rest my head against the seatback and savor the air conditioned breeze filling the cab from the vents.

In the back I hear the patient worrying to my partner about the duration of the hold she is on. She states last time she was in the hospital ten days. That she was homesick.

I think of her home. If services become involved, as our report and the chapter hold by law enforcement will surely necessitate upon hospital discharge, how long would a change last in the face of the apartment’s occupants’ life choices? How do we as a system assist positive change and support public health, combining compliance with medication regimens and sanitary living conditions? Such a front row seat we have to the inner workings of a myriad of homes. With that great privilege comes great responsibility but sadly too often the workings of the system seem as foggy as that apartment. The horizon seems full of potential growth as we strive to learn to combine street paramedic roles in collaboration with hospital personnel, identifying and implementing public health and social services.