Musicians who are dealing with mental health and substance abuse problems in Austin, Texas, can get help from an organization there that provides reduced cost care —basically whatever the musicians can afford to pay— from cooperating doctors and therapists.

In the 10 years he spent driving an ambulance in Atlanta, former paramedic Kevin Hazzard rescued people from choking, overdoses, cardiac arrest, gunshot wounds and a host of other medical emergencies.

He frequently found himself practicing medicine in unsafe settings, either along the side of a highway as cars whipped past, or at the scene of an assault, where either the patient or the spectators might have weapons. “There are a lot of situations like that where it’s just not practical to wait for it to be completely safe and you gotta just try to weigh the odds,” Hazzard tells Fresh Air’s Terry Gross.

In his new book, A Thousand Naked Strangers, Hazzard chronicles his experiences as a paramedic — and explains how it is that so many of his patients came to him partially clothed.

Kevin Hazzard worked as a paramedic for 10 years in Atlanta. Lauren Pressey/Simon & Schuster hide caption

toggle caption Lauren Pressey/Simon & Schuster

“There’s just the huge range of people for whatever reason — whether it’s mental illness or just had way too much fun last night — find themselves out in the street partially or completely naked and need to be dealt with in one way or another,” Hazzard says.

But Hazzard says that even when he saved a life, his patients weren’t always grateful. “Just as you’re expecting a thank-you, someone says, ‘Hey, when you pulled me off that balcony that I was dangling from, you ripped my shirt!’ “

Interview Highlights

On why he always moves out of the way of ambulances

There’s a presumption that when you see an ambulance or a firetruck or a cop car that the person behind [the wheel] is a professional — they’ve been trained and they know. I received zero training. My first job was with a private ambulance service … taking people to and from appointments. There was no training program. There was really no hiring process. They never verified they actually had my EMT numbers. They asked. I said, “Yes.” They believed me; they gave me a job. …

So I showed up that first morning, and my partner handed me the keys. I just assumed he was going to be driving. So we go to breakfast and within a few minutes we get a call, and the next thing I know I’m racing down the street and he’s like, “Turn your lights on! Flip over! Cross the double yellow line! Switch back! Blow your horn!” My friends will tell you, I’m a horrible driver, so me behind this 15,000-pound ambulance screaming down the street, cars peeling out of the way, immediately removed all [my] confidence in people coming at me with sirens. I move now, really fast.

On why respiratory calls can be the most rewarding

Respiratory calls are really, really common — which was great because there are few things that you can do outside of the hospital that take someone from near death to looking at you and saying, “Do I still need to go?” And respiratory is one of those calls. We ran so many of them on everything from infants to the elderly, it was great. Everybody thinks shooting is exciting, “Oh, man, I’m going to run to this shooting, and I’m on my way!” And it’s crazy. There are cops there and police helicopters and it’s madness, but there’s really nothing for you to do. That’s really a job for the surgeons. Whereas a respiratory call, that person is in acute distress and they are going to die, you can see it in their face, and they know it and you know it. And you just happen to have this bag full of tricks that you get to kneel on their floor and talk to them and calm them down and slowly begin to give them one medication after another. Sometimes it doesn’t work, sometimes you throw the book at them and they’re still just about as dead as when you found them, but oftentimes you can make a huge difference in that person’s life, and it’s both rewarding and exciting because you wouldn’t be there if you didn’t want to open your bag and start throwing medicine at people.

On treating “speedball” overdoses, in which the patient has mixed heroin and cocaine

The one that can be the trickiest is the person who has overdosed. So you arrive, and they have all the signs of a heroin overdose, and so you have Narcan, which immediately reverses some of the effects, basically the central nervous system effects of the heroin. So, the heroin, when there’s too much of it, it essentially tells your brain, “Hey, there’s no reason to breathe, just relax, you’re good.” And that’s how people die. So you show up, there’s a guy with needles, brown powdery substance, he’s blue, and you think, “Oh, heroin overdose, this is no big deal, I’ve done this 10,000 times.” And you give him some Narcan thinking, “Hey, I’m just going to make him breathe.” Now the heroin’s gone and all that cocaine is still there, and he pops up and he’s like, “Hey! What did you do to my heroin?” And now you’ve got this very large, very angry, very confused person running around with a head full of coke, and you’re usually in the backseat of a car or crammed into a tiny little bathroom, or a bathroom stall in a restaurant, and all of a sudden this person pops up, and invariably they’re bigger than you and stronger than you and they’re half-naked and sweaty, so you can’t get a grip anyway. Those get ugly in a hurry.

On Do-Not-Resuscitate orders

If you think about it, [at] Thanksgiving you can’t even get all your family members to agree on whether they want fresh or canned cranberry sauce, right? I mean, the simplest decision in the world, and you will get four brothers who will fight to the death because they all have a different opinion, and then add to that, now, that decision is what to do if mom drops on the floor. A lot of times, it kind of depends on who the first person is to arrive. Does she live with one of the sons who wants her to be revived? Does she live with one of the children who doesn’t? Even if there’s a DNR that has been signed, oftentimes people can’t find it. So then you have to say, “OK, we don’t have, technically speaking, a valid DNR, so we have no choice but to work,” and the family will get angry with you and say, “No, no, no, that’s not what she wanted!” But you can’t prove to me that’s not what she wanted, and how do I know that you don’t have a sister who is on her way right now who knows that there’s no DNR and who is gonna come flying through that door and wonder why we’re not doing anything?

On delivering babies

Delivering babies is a huge mess in an ambulance. Hospitals are really well-suited for it. So it was such a tricky thing, because when you got one of those calls, your first reaction would sort of be dread: “Oh, no, there’s so much I’m going to have to do here, this is such a circus.” Hopefully they were at least in an accessible place, not in a car on the highway, which just really complicates everything. It’s one of those things that it’s not good until it’s all over with. Don’t forget, these are people who are enduring a natural childbirth, so they aren’t happy to see us. There’s no joking with a woman who is way deep into a natural childbirth and is going to do it on the living room rug. She’s not in the mood to smile or necessarily even be cooperative. … All of a sudden there’s this child and everybody is smiling. … It wasn’t one you always looked forward to, but it was one in the end that everybody always seemed to enjoy.

On how he knew it was time to retire from being a paramedic

There were a couple little hints and warning signs. I ran a shooting one day, and I got too close to the person and stepped on a piece of their skull. And I didn’t realize it until I got home the next morning, and it was stuck in the tread of my boot, and I thought it was a stone. And I pulled it out and it was skull fragment. I sort of laughed. My wife was horrified, and the look on her face let me know that, oh, wow, my outlook has swung in a weird direction and that’s troubling.

Those things happen little by little over time, and I guess there are hints and warnings that, hey, you’re being a little too cavalier about what you’re doing. But the moment that it hit me … it was a woman who she was caught in bed with her son-in-law by her daughter, and the son-in-law jumped out, and the daughter beat the mother with a bat. And we got there and she was really badly injured, and she was on the floor at our feet, and this crazy scene is happening all around us — helicopters and cops and this patient who desperately needed our help — and I remember yawning, and it was probably 2 in the morning and I yawned. It wasn’t like I didn’t care whether or not good things happened to this woman. I had done it so many times that there was a certain ho-hum nature about it, and there can be nothing ho-hum about trying to save someone’s life. And when you begin to think, “Well, I’ve done this before and I’ll just do it again and I’m just doing a job,” that’s when you make mistakes. And that was the first real indication to me that, man, I’ve been at this too long and I need to go ahead and get out.

When she first heard that California’s new aid in-dying law was signed, Dr. Carin van Zyl was relieved to hear that assisted death would be an option for her if she ever needed it herself. But as a palliative care doctor at the University Of Southern California Keck School Of Medicine, she’s worried the law might lead people to consider lethal medications over other options that may better accommodate their wishes.

“Patients feel as though their choices are between untreated suffering or physician-assisted suicide,” she told NPR’s Renee Montagne. “Palliative medicine, when it’s applied skillfully and at the right time, often relieves most of the suffering that prompts people to ask for [death] in the first place,” she says.

Van Zyl is head of palliative care medicine at Los Angeles County-USC Medical Center. Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News hide caption

toggle caption Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News

But palliative care, which is focused on managing symptoms and relieving pain, isn’t available to everyone, van Zyl says. There are smaller hospitals that don’t have palliative medicine teams, and it may be hard to get treatment even in urban areas. Van Zyl thinks more work should be done to make palliative medicine more accessible. “I worry that we make [lethal medication] available before we put the necessary effort forward,” she says.

Not everyone can be helped with palliative care, van Zyl says, and some people truly would have benefited from the aid-in-dying law had it been passed earlier. “I think about those patients all the time. I do recall a patient who understood that his death would be sudden and unpredictable and likely quite painful.”

He had a cancer that had spread and become intractable. A tumor developed in his neck that was swelling into both an artery and his windpipe; eventually it would connect the two. “This gentleman with very little warning might have his airways flooded with blood, and he would drown,” van Zyl says. “He asked if it would be possible to shorten his life before that.”

The care team was able to administer pain medication that would ease his death when it happened, which worked, van Zyl says, but he wasn’t able to die in the way he wanted — at home, surrounded by his family. Aid in dying would have offered more control over his situation, van Zyl says.

Still, the reasons why people choose aid in dying can be complicated. “You’ll notice in the Oregon data, many people chose this option not because of physical suffering. It was the loss of dignity, control and independence,” she says. “I would imagine writing a prescription for somebody for whom palliative sedation is not an option or would not relieve intolerable physical distress. I struggle with emotional and existential requests.” Times like that, van Zyl says she would rather administer palliative care.

Dr. Carin van Zyl talks to patient Jose Garcia Flores about his treatment options for his advanced stage colon cancer in October. Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News hide caption

toggle caption Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News

Choosing the best course of action is a conversation that van Zyl says she’ll continue to have with her patients. “Palliative medicine discussions are about learning the story of the person, helping this patient navigate choices. If [death] is an option that gets them closest to the things they hold dearest, then we will explore those things honestly.”

When East Cleveland’s emergency medical squad gets called to treat a man with a severe nosebleed, it’s a pretty run-of-the-mill case.

The patient walks woozily out to the ambulance from a tan house on a tree-lined street. Anthony Savoy, the head medic, calls ahead to University Hospitals, which has the closest emergency room. Savoy wants to make sure the ER has space for the patient.

The man gets in that day, but it was by no means guaranteed. For years, it’s been common practice for University Hospitals to switch its status to diversion.

That means when Savoy would call the hospital, people in the emergency department would say they didn’t have the room or the staff to handle the patient. The EMS team then would have to drive to another hospital — often the Cleveland Clinic — about a mile away.

“If we get diverted and then we get a call while we’re at the hospital, our response time will be lengthened by maybe a minute, maybe two minutes,” Savoy says.

A minute or two delay may not seem like much, but it can be crucial for some patients, says Dr. James Feldman, an emergency medicine doctor in Boston. “We have strong evidence that people who have critical illness or injury who have a delayed time to treatment do worse,” he says. Patients who have had a stroke or a heart attack are prime examples.

A study released earlier this year found that heart attack patients whose ambulances were diverted from crowded emergency rooms to hospitals farther away were more likely to be dead a year later. And before that study came out, the Institute of Medicine had taken a look at the increasing use of diversions by hospitals nationwide, and recommended against that sort of rerouting.

Yet, emergency departments across the country, including those in Cleveland, continued to divert patients — often stepping up the frequency. Boston’s Feldman says hospitals across the country routinely operate with thin staffing and find themselves coping with too many patients.

In Cleveland this year, University Hospitals temporarily closed its main campus emergency room to certain patients for more than 550 hours. Another large health system, MetroHealth, clocked more than 400 diversion hours.

Jane Dus, chief nursing officer at University Hospitals, says an aging population and hospital closures have increased the demand on emergency departments. “We’ve seen a 56 percent increase in our squad volume over five years,” she says. “So we’re getting many more squads coming to us.”

Dus recently joined Cleveland-area hospital leaders in negotiating an agreement to stop ER diversion. Indeed, all four major health systems in Cleveland say they will accept all ambulances starting Feb. 15.

If the hospitals are successful, the region will join a select few that have tackled the issue. After years of trying, the Seattle area has stopped nearly all diversions.

Under federal law, every hospital is required to evaluate patients who arrive in the ER, and stabilize them before transferring them elsewhere. But the law doesn’t cover patients in ambulances that are diverted before patients are ever seen.

Massachusetts passed regulations in 2009 to ban ambulance diversions after voluntary attempts failed. Feldman says hospitals there had to reevaluate operations, in some cases urging doctors and patients to schedule elective surgeries closer to the weekends to free more hospital beds throughout the week.

But changing the way an ER responds is complicated because emergency departments routinely operate with minimum staffing and beds, Feldman says. “The staff are reasonably fearful that the next critical patient is going to push them over the brink of patient safety,” he says. “They really can’t handle another patient.”

Dr. Alfred Connors, MetroHealth’s chief clinical officer, says there are things the hospital can do to be better prepared. “This does obligate us to take steps to correct problems that are correctable that will allow us not to go on diversion,” Connors says. “It’s not just simply, ‘We’re not going to go on diversion,’ and everybody just sits and hopes that everything will be better.”

Adding bed capacity and refocusing on staff are part of the fix, he says. “It’s an issue of, do we have enough beds open, do we have the proper staffing, do we have the capacity in the emergency room.”

MetroHealth is frequently the busiest emergency department in the city, and the hospital has struggled with diversions before, logging nearly 1,000 hours of diversion in 2013. Connors says the hospital worked to reduce that number, getting down to less than 150 hours of diversion status in 2014. But in 2015, diversions rose again.

There are two hospitals in Cleveland that rarely if ever go on diversion: the Cleveland Clinic’s main campus and St. Vincent Charity Medical Center.

The Cleveland Clinic’s main campus logged more than 500 hours of ambulance diversions in 2013, but reduced its diversions to two episodes lasting a total of about 10 hours in 2015.

Dr. Stephen Meldon, a leader in the emergency department at the Cleveland Clinic, says change has to happen beyond the emergency department. The clinic has diversions at other regional hospitals in its system and will have to stop those as well, if it’s to meet the demands of the new ban.

The ban will “drive people to actually address efficiencies throughout the day,” Meldon says, “and not use diversion as a crutch, to not be doing the work they should be doing.”

The small St. Vincent Charity Medical Center in downtown Cleveland hasn’t gone on diversion since 2012. “It’s a matter of working together as a team,” says Beverly Lozar, the hospital’s chief nursing executive. “It starts every morning at 8:30. We have a huddle of all the nursing directors and all of the other clinical and support directors just to kind of review the day.”

Still, Savoy is skeptical that University Hospitals and MetroHealth can end diversions. Just hours after Savoy dropped off his nosebleed patient, University Hospitals stopped taking all but the most critical injuries for nearly four hours.

“My concern is, all of a sudden you guys are willing to put this on paper and say that you’re going to do this,” he says. “What was stopping you guys before? You know, why now?”

Savoy and others on the squad are worried that the emergency departments will stay crowded. It’s something local leaders say they’ll work to avoid.

This story is part of NPR’s reporting partnership with WCPN and Kaiser Health News.

Butter-flavored popcorn oil is in high demand at Oasis Foods, a manufacturer of cooking oils, mayonnaise and other products that restaurants and distributors often purchase by the ton.

“We get a rush this time of year with all the movie-going at the holidays,” says Duke Gillingham, president of Oasis, at his factory in Hillside, N.J., just west of Newark Liberty Airport.

The company’s health insurance coverage is not as popular as its popcorn oil. Oasis offered health insurance to all employees for 2015, to comply with a new Affordable Care Act mandate. And while some employees did sign up for the insurance — the company doubled the number of people on its health plan over previous years — about two-thirds of the employees declined the coverage. With monthly premiums of roughly $350 for a family of four, and with a $2,500 annual deductible, it was too expensive for factory workers, many of whom earn between $10 and $15 an hour.

Gillingham says he hasn’t been able to find decent insurance much cheaper than that, and he cannot afford to significantly raise his employees’ wages.

“The sad fact is we’re in a very competitive business,” he says. “We wish we could make [insurance] more affordable, but it’s essentially what the business can bear. If we don’t watch what we’re doing, we can be high-cost, and that doesn’t serve any of the employees well.”

Companies Look To Avoid Penalties

Oasis Foods, a subsidiary of a Swedish food manufacturer, has about 180 workers. As of Jan.1, smaller firms — those that employ between 51 and 100 workers — are being phased into the same mandate that Oasis faced in 2015. Companies must offer affordable coverage to all employees, and will be subject to a penalty if their workers instead turn to the health exchange to buy subsidized coverage.

There’s no penalty for companies, it turns out, if workers qualify for Medicaid — though there could be controversy.

At firms like Oasis, low-wage workers are candidates more often for Medicaid than for the state or federal insurance exchange.

To qualify for Medicaid, applicants may earn no more than 138 percent of the federal poverty level — or roughly $16,000 for a single person and around $33,000 for a household of four.

Employers have not historically played a significant role in helping workers enroll in Medicaid. But Gillingham’s insurance broker told him about a startup called BeneStream, which is based in New York City and facilitates enrollment in the government program.

Company Shifts Insurance Costs To The Government

Founded two years ago with seed money from the Ford Foundation, BeneStream now helps more than 6,500 workers at 125 companies across the country get Medicaid. CEO Benjamin Geyerhahn says moving workers from private insurance to Medicaid helps firms shift their costs to the government.

“The savings is quite significant,” he says. “Our average is about 250 percent — so about two-and-a-half times the money you spend on us comes back to you in the form of saved premium.”

Geyerhahn says going onto Medicaid, which is nearly free for employees, is a good deal, though it lacks the generous benefits of more expensive plans. If employees make so little that they’re eligible for Medicaid, he says, they probably can’t afford regular insurance premiums, especially when combined with the high deductibles that undermine much of the benefit of insurance.

“Yes, this [level of coverage] is something that will help them if they get in a car accident or have a heart attack,” he says, “but this isn’t something that’s going to help them manage their health over the course of the year.”

Wal-Mart, McDonald’s and some large companies have drawn fire for not providing employees with health insurance, but instead relying on taxpayers to fund workers’ health needs via Medicaid.

Ken Jacobs, chair of the University of California, Berkeley’s Labor Center, says companies whose workers get Medicaid should bear some of the burden of the cost to taxpayers.

Critics Think Employers Should Pay Bigger Share

“Those employers should be paying more into the general pot that pays for health care, rather than putting those costs onto everyone else,” he says.

California legislators considered imposing a state tax penalty for companies whose workers get Medicaid, but lawmakers ultimately rejected the proposal.

Linda Blumberg, an economist at the Urban Institute, says that whether you are looking at a vast company like Wal-Mart or a modest-sized one like Oasis Foods, compensation is about trade-offs. The more you pay for people’s insurance, the less you have to put in their paychecks.

“When workers are low-income,” Blumberg says, “I would rather that we publicly finance their medical care, make it very accessible to them, have low cost-sharing so that’s not a barrier to them getting necessary care, and let them have a little bit higher wages in order to compensate.”

And even the large increases in the minimum wage currently being contemplated or phased in by several states and cities might still not be enough for those workers to afford most employer-sponsored insurance, given the high premiums and deductibles of such plans.

At Oasis, Gillingham says his company pays a lot in taxes, so getting almost-free health care for some workers amounts to a “fair deal.”

He contrasts this system to one he and his family of six experienced in England.

“My kids didn’t suffer from having a five- or six-minute checkup,” he says, compared with doctor visits in the United States — that may have been twice as long, and at much higher expense, but without any noticeable difference in results.

“We didn’t see any of the demons that people speak of when they talk about socialized medicine,” Gillingham says. “There were no lines, no poor standard-of-care.”

But despite being relatively upbeat about government healthcare, he concedes that Oasis workers so far have given Medicaid mixed reviews. Some doctors and hospitals take the insurance, but many don’t.

Still, that’s true of most health insurance, Gillingham says.

A Gallup poll last month found that 67 percent of Americans, in general, are satisfied with the country’s health care system, compared with 75 percent of people who are on Medicaid.

“I think the system is evolving,” Gillingham says. “I don’t know where it’s going to go, but I know it’s going to change, and we need to adapt and make use of the system in the best way possible.”

This story was produced as part of NPR’s partnership with WNYC and Kaiser Health News.