PORTLAND — Trisha Preston was transporting a patient in a mental health crisis in the back of her ambulance when suddenly the woman undid her seatbelt, jumped off the gurney and began attacking the veteran paramedic, punching her and pulling her hair. By the time Preston’s partner wrestled the woman to the floor, Preston had a concussion and bite marks on her arms.
“It took me a good couple of months to get it out of my head. I was constantly thinking about it,” Preston said. “We’re all on high alert these days.”
Her experience is part of a rash of attacks in recent months on paramedics in this Pacific Northwest city as they respond to a growing number of 911 calls for patients in mental health or drug-related crises. The uptick in violence is so severe that the private ambulance company that holds Portland’s 911 contract is training more than 500 of its employees in defensive tactics.
The company is trying to better understand what’s happening in the field.
“The frequency appears to be increasing. The severity appears to be increasing,” said Robert McDonald, an operations manager with American Medical Response. “This has gone unreported in so many ways that it’s difficult for us to get our arms around.”
The increase in assaults dovetails with a new policy for the transport of patients in a mental health crisis that grew out of a 2012 federal investigation that found police used excessive force against those with mental illness.
Now, paramedics — not law enforcement — routinely take patients on mental health holds to the hospital, most often to a new psychiatric emergency room created specifically to stabilize those in the throes of a psychiatric crisis. In the past, police transported these patients in the backs of patrol cars, in handcuffs, to traditional emergency rooms less equipped to help them.
The policy puts the city at the forefront of a growing national movement to decriminalize mental health by treating a psychiatric crisis as a medical emergency similar to a heart attack — not as a crime.
Portland drew key parts of its new approach from Alameda County, Calif., where paramedic transports and a psychiatric emergency room model have reduced hospitalization rates for mental health emergencies by 85 percent, said Scott Zeller, vice president for acute psychiatry for Vituity, a multistate medical consultancy group. Cities from Billings, Mont., to San Bernardino, Calif., are also re-examining how they treat people in a psychiatric emergency.
“If an ambulance comes to your house and takes you somewhere versus if the police come and take you away, that’s a whole different thing,” Zeller said. “These are medical issues … and when you have an exacerbation, you need the same type of emergency help that you would get if you fell down the stairs.”
For paramedics, however, the shift that began in 2016 has meant a significant change in their daily work.
For the past three years, the ambulance company has seen 911 calls for behavioral health increase 3 percent to 5 percent each year, while overall call volume has also increased. Behavioral health calls come with specific challenges, “where we may have a patient who is compliant, calm, easy to work with, and for whatever reason, they turn,” McDonald said.
The policy on ambulance transportation is also paired with a new approach toward handling police calls for those in a mental health or drug-related crisis. Under the settlement with the federal government, Portland now deploys a team of specialized officers who are paired with outreach workers from a local organization called Cascadia Behavioral Healthcare. The force has also given 100 front-line officers enhanced training to address mental health issues that arise on service calls.
Mental health advocates applaud the changes but caution the fallout for paramedics points to a much larger problem with the mental health care system in Oregon and nationwide.
Oregon’s mental hospital is so overcrowded that the state recently was sued for making court-ordered patients languish in jail as they awaited beds. Overall, the state lacks mental health care options that fall between the extremes of going to the emergency room and being institutionalized for weeks or months.
Walk-in options for people who recognize they are in crisis — or headed that way — are almost nonexistent, making paramedics the front-line caregivers when those symptoms reach a crisis point, said Chris Bouneff, executive director of Oregon’s chapter of the National Alliance on Mental Illness.
Advocates also worry headline-grabbing violent incidents reinforce the stereotype that people with mental illness are dangerous.
“People with a mental health diagnosis are much more likely to be the victim of a violent crime (than) the perpetrator. So it’s important to bear that in mind,” said Sarah Radcliffe, a managing attorney at Disability Rights Oregon, which advocates for mental health patients.
