For Renegade Ambulance Riders,
the Man in the Minivan

San Francisco Fire Department Captain Neils Tangherlini is not your usual firefighter
or emergency technician. Working alone, his mission is to connect frequent flyers, those who routinely abuse expensive emergency services for non-emergencies, with the services and assistance they need.
Photo(s) by Luke Thomas

By Emmett Berg

December 17, 2007

Mr. R is flat on his back, and turns away best he can from the man in uniform. San Francisco Fire Capt. Niels Tangherlini asks Mr. R. where he can find him later if he wants to decide later to come in from the streets.

"I be everywhere," Mr. R said. "I got no turf."

He looks like he wants more shuteye.

Capt. Tangherlini persists, his voice conversational about the "good stuff" in housing and services he can offer, as long as he can find him or at least know where to look. Mr. R knows we're watching, and it looks like he wants to try.

A minute later, Mr. R turns his head over and says: "I'll be here."

That's an unacceptable forwarding address, given that Mr. R. is in a bed parked in hallways of the emergency department at San Francisco General Hospital.

Mr. R is one of about a half dozen people laid out on stretchers in the hallways of the ER, still dozing at 9:30 a.m. on a recent Monday. Some gentle snoring audible, the most fuss we heard was from a gentle nurse exhorting a woman to sit up and eat a breakfast sandwich.

In the interim before the hallway sleepers are kicked out of emergency, Tangherlini is seizing the moment. A systems buster for chronic inebriants like Mr. R., Tangherlini takes a paramedic's background to the job with a social worker's calm assurance. Tangherlini works closely with hard cases, and steers them the city's two Homeless Outreach Teams of licensed clinical social workers, people who in turn can lead the way to housing and help.

On hospital beds here at General include renowned "frequent flyers" - people requiring recurrent, sometimes daily paramedic transport to area hospitals. The wasted resources stack up when the same person requires a hundred or more ambulance rides in a single year.

A map of San Francisco illustrates a majority of frequent flyer calls
orginate in the Tenderloin and downtain areas of San Francisco.

Passion for the job can erode when ambulance crews are dispatched to the same people over and over because of chronic inebriation. Clients who call for help can become abusive of paramedic staff. Worries that a paramedic will witness murder in the course of domestic violence, or be hurt while on a case, are more than just fears: they happen.

The memory of a partner who quit paramedic work in part led Tangherlini to pursue a degree in social work in a quest to "change the experience" for doctors, nurses and emergency responders. Now his special assignment follows a route trod also by chronic users: the Tenderloin, intensive case management centers, and the emergency room.

As Tangherlini was making his pitch to other patients in the hallway, his cell phone rang and his face lit up with the realization it was Ms. A., a known renegade in three counties. By Tangerhlini's estimation, Ms. A rides ambulances more than 100 times a year for the past few years running. And here was Ms. A calling on the cell phone saying she had decided to come in from the streets into supportive housing.

"This would be big," he said in the minivan on the way over to the Oshun Center for women at Turk and Taylor streets.

At the Oshun Center, the hardscrabble experience of staff, some who are recovering addicts, adds credibility as they work to help the Tenderloin homeless and other women in dire need. A staff member says she confides in prospective clients, telling them, "I know what hard dope is. I'm just feelin' today, is all." Still it can be hard to gauge the resolve in another's eye.

Ms. A greets us but stays seated in her chair in the front room of the Oshun Center. A kind of courtship ritual unfolds and Ms. A., sated it seems, appears ready to follow Tangherlini into the minivan. But then her dismay is evident when another client seated in a nearby sofa asks staff to call an ambulance because of pain in her legs.

While the call is made, Tangherlini crosses the room to assist her. Eventually a S.F. Fire Department paramedic crew arrives, one of them groaning at the woman, "Not you again."
With the handful of paramedics focused on the other woman, Ms. A changes her mind and gets up to leave. Ms. A said it was too early, at noontime on a nice day, to go "into services," Ms A said. She said she was just going down the street and we could find her.

When Tangherlini disentangled himself, we combed the streets in the minivan.

No Ms. A

"She's had a history of saying she was done and then running out like this," Tangherlini said.

* * *

Update: Ms. A entered permanent supportive housing last week, according to the city's housing and urban health medical director Dr. Josh Bamberger. Ms. A's chances of staying there are much better than average.

Bamberger said the city's 4,000 units of permanent housing for the homeless had a 90 percent retention rate over the last year. The remaining 10 percent, he said, were moving to other housing or supporting service programs. Evictions comprise 2 or 3 percent.

Captain Neils Tangherlini

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