By the time medics arrived, Tyre Nichols was sitting on the ground, handcuffed and propped against a police car.
The 29-year-old’s face was bloody and he was groaning in pain. On Jan. 7, after pulling Nichols over for a traffic stop, Memphis police officers had tased him, pepper-sprayed him, punched him, kicked him in the head, and beaten him with a baton. He weighed about 150 pounds, according to his mother, and suffered from Crohn’s disease.
Other than helping Nichols back up when he slumped over, the emergency medical technicians who’d arrived on the scene barely engaged with him, according to police body camera footage of the incident. As they stood nearby, Nichols collapsed onto the asphalt and writhed alone for minutes at a time.
National and state emergency medical services guidelines call for medics — at a bare minimum — to immediately check their patient’s airway, breathing, and vital signs. For head trauma, they would also immobilize the spine and neck, and give oxygen to prevent brain damage. None of that happened for Nichols. “They didn’t do bread and butter EMS,” said Ameera Haamid, an emergency medicine physician at the University of Chicago. “They didn’t do step one, which is, assess your patient.”
Even though they could have given him oxygen, administered intravenous treatment, and monitored his heart, the EMTs did nothing more clinical in the first 19 minutes they were on scene than shine a flashlight on Nichols. But all emergency clinicians are taught and trained that every minute matters in a medical crisis. “Their patient was in obvious distress,” said Sullivan Smith, a physician and member of Tennessee’s Emergency Medical Services Board. “It’s obvious to even a layperson that he was in terrible distress and needed help, and they failed to provide that help. They were his best shot. And they failed to help.”
Twenty-five minutes after police called for them to treat a pepper spray injury, a transport ambulance showed up to take Nichols to the hospital, where he died three days later.
In the wake of Nichols’ death, and with up to 20 more hours of body camera footage of Nichols’ beating and arrest still to be released, the public is scrutinizing not only the actions of police, but those of emergency clinicians. Following second-degree murder charges for six officers involved in the beating, the Memphis Fire Department also fired the two EMTs and their lieutenant for their “actions or inactions on the scene that night,” including a failure “to conduct an adequate patient assessment.” During an emergency meeting held Friday, Tennessee’s EMS board voted unanimously to revoke their licenses. Dennis Rowe, a board member and ambulance service operator, said there was “every reason to believe” that the EMTs’ inaction “may have contributed to the demise of that patient.”
Nichols, some say, is just the most recent example of EMS hesitating to administer appropriate aid to a severely injured Black man in police custody. “People are now starting to say, ‘Now wait a second, other people in uniform showed up too. What did they do? How did they act?” said Doug Wolfberg, a leading EMS industry lawyer and former EMT, and are “rightfully questioning the totality of this response by public safety.”
For Black communities, questions about whether they’d be cared for if they needed medical attention in a crisis are not new. “What does one have to do to be afforded the basic level of assessment?” said Italo Brown, an emergency physician at Stanford University and a health equity and social justice curriculum leader at its medical school. “Anywhere in America, if you’re in trouble, help will come. But if you’re a person of color, you have to think twice.”
Emergency clinicians, categorically, work in the eye of a crisis or in its direct wake.
They are often the first person to help someone on the worst day of their life — after a shooting, a building collapse, an attempted suicide, a car crash, a heart attack. Exposure to human suffering — to violence and trauma — is a routine and unavoidable fixture of the job. On highway shoulders, in shopping malls, and at strangers’ homes, in bad weather and around the clock and under immense time pressures, they handled 43.5 million medical calls in 2021 without the privilege of time, equipment, personnel, and training that’s afforded to hospital-based health care workers.
But in the U.S., EMS and law enforcement are also deeply intertwined. In a number of other high-profile police brutality cases — including the deaths of Elijah McClain, George Floyd, and Eric Garner, all of whom were Black — paramedics also have been scrutinized for their handling of someone in police custody. “The death of Tyre Nichols forces us to confront yet another moment where both those who have sworn to protect and those who have sworn to treat appear to have breached their duty,” wrote Donell Harvin, a homeland security and public health expert with EMS and law enforcement experience, in Politico.
Many EMS agencies operate out of the same jurisdiction as law enforcement agencies, which experts say leads to fraternization between police and emergency medics. That collegiality might make EMS personnel more likely to defer to the police, in part for fear that they’ll be perceived as obstructing justice by caring for someone who the police consider a suspect.
“They have a duty, I think, to directly declare to law enforcement this is a patient,” said Wolfberg, the EMS lawyer. But many EMS agencies and most states lack clear laws and guidelines on the point at which a detainment becomes a patient care setting, he said. Whether and how EMS can assume control of a law enforcement scene is, according to Wolfberg, “a very amorphous and potentially dangerous gray area.”
“They would have to ask the people with badges and guns to stand down,” he said.
Christian Ventura, an EMT, nationally certified EMS educator, and Johns Hopkins public health researcher, said it didn’t surprise him to see footage of EMTs’ apparent lack of empathy and action for Nichols. “I’ve seen it happen so many times,” Ventura said. “If it seems like we’re not treating someone as human, it’s because we’re not thinking of them as human.”
“If it seems like we’re not treating someone as human, it’s because we’re not thinking of them as human.”
Christian Ventura, EMT, EMS educator, and Johns Hopkins public health researcher
This can also be true in cases that don’t involve police brutality. Police footage from last December, for example, documented how paramedics treated Earl Moore Jr., a Black 35-year-old who was sick and hallucinating from alcohol withdrawal in Springfield, Ill. Police officers first responded to a call for help from someone in Moore’s home around 2 a.m. Once they saw the state he was in, they felt that Moore was in enough medical distress to call, in turn, for EMS. Shortly after, a pair of paramedics entered his bedroom, where he was lying on the ground. “You know what, I am not playing. Sit up. Quit acting stupid. Sit up. Sit up now. I am not playing with you tonight,” one of the paramedics said. “You’re gonna have to walk cause we ain’t carrying you.”
Outside the home, body camera footage shows the other paramedic slamming Moore face-down on a stretcher; together, they pulled straps tight across his back. Court audio shows that during the ensuing three-and-a-half-minute ambulance ride, they refused to take Moore’s vital signs. He was pronounced dead at the emergency room. “They tied him down like some kind of animal and killed him,” Moore’s mother, Rose Washington, said of her only son. A coroner ruled Moore’s death a homicide by compressional and positional asphyxia, and the two paramedics now face first-degree murder charges.
Last August, in another Illinois incident, a first responder was fired after his patient stopped breathing while strapped to an ambulance stretcher, according to reporting by the Chicago Tribune. Police body camera footage shows medics didn’t assess Leonardo Guerrero, 44, despite the fact that he was found nude and intoxicated in a parking lot and was in a respiratory crisis. Strapped in and handcuffed to a stretcher, Guerrero “was lapsing in and out of consciousness” and gasping for air during the three-minute ambulance ride as paramedics ignored him. As his breathing slowed, paramedics “did not assess or care for the patient at all,” an official report said. Guerrero was pronounced dead in the emergency room, and his death was later ruled a homicide by the Cook County medical examiner’s office.
Guerrero’s loved ones, like Moore’s, say they believe paramedics discounted his care. “They just saw a homeless person in their eyes. They saw no value,” Guerrero’s sister told the Chicago Tribune.
Because emergency clinicians have to make split-second decisions, and because they depend on patterns and instincts to do so, they are also vulnerable to developing a reliance on stereotypes and unconscious biases, experts told STAT. They may, for example, be more likely to assume that an agitated unsheltered person is drunk or using drugs, rather than consider that they have low blood sugar or oxygen levels. When a patient is in police custody, EMS clinicians may be less likely to perceive the patient’s pain and injuries as genuine and instead attribute them to incarceritis, industry slang for exaggerating symptoms of illness or trauma in order to avoid jail.
In the past decade, research has begun to document how social factors such as gender, race, language, housing status, and income level can affect the quality and nature of emergency medical care. EMS is more likely to bring Black and Hispanic patients to hospitals that predominantly treat low-income and underserved patients, which often have lower quality of care, compared to white patients in the same geographic area. Black patients are 40% less likely to get pain medication than their white counterparts from emergency medical responders. Pulse oximeters, an essential EMS tool, overestimate oxygen levels in people with dark skin tones, making it less likely for emergency clinicians to detect a life-threatening need for oxygen.
In 2019, just 8% of EMTs and 5% of paramedics were Black, and about 13% were Hispanic.
The job’s working conditions can also make emergency clinicians more vulnerable to mistakes and biases. EMS, as a profession, is a tough one to endure: The work is grueling, traumatizing, demeaning, and often thankless. Paramedics and EMTs make, on median, about $37,000 per year; approximately 1 in 10 do it for free as volunteers. Surveys suggest that most, if not all, are spit on, bitten, punched, stabbed, shot, or otherwise assaulted while earning that meager pay. “It cheese-graters your soul,” an EMT in Homer, Alaska, told STAT last year. Unsurprisingly, emergency clinicians routinely struggle with PTSD, suicide and suicidal thoughts, burnout, and job dissatisfaction; EMS agencies now experience a full staff turnover every three to four years, industry surveys show, with more than one-third of all new hires leaving within the first year of employment.
The field is also overwhelmingly white and male. In 2019, just 8% of EMTs and 5% of paramedics were Black, and about 13% were Hispanic. Research on LGBTQ personnel, scholars have noted, “is largely absent,” as are studies of the workforce’s socioeconomic status, language, religion, and ability.
It’s “very much an old boys club,” Sylvia Owusu-Ansah, the diversity and inclusion director of the National Association of EMS Physicians told STAT last year. “I’m pretty much on the national committee of every EMS organization that exists out there, and over 90% of the time, I’m one of the few women, I’m the only person of color, and I’m the youngest person.”
Steven Nelson, a Black, gay paramedic in Houston, has been called the n-word by patients and heard white co-workers use the slur. “If we are being honest here, I started to think people in this field were no different than some law enforcement officers I encountered,” Nelson wrote in 2021 about hearing colleagues voice negative stereotypes about Black people and show a lack of empathy and sympathy toward people of color in their care.
Taken together, the high-pressure, resource-limited nature of EMS work, the field’s lack of diversity, and the reality of both racism and unconscious biases can all work together to the detriment of marginalized patients, experts told STAT. “The more burned out you are,” Haamid said, “the more heavily you are going to be relying on those biases.”
More broadly, the U.S. has a long, fraught history of medical apartheid in which marginalized communities, in particular Black people, have been sterilized, experimented on, exploited, and underserved by medicine. Experts told STAT that many vulnerable communities have been wary of calling 911 long before Nichols’ death. “It would be ridiculous for me to say that now this is going to make people suspicious,” Ventura said. “They already are.”
Haamid recently experienced firsthand the complications of calling 911 as a Black person.
Her dad, who has heart problems and is on blood thinners, was in severe abdominal pain. He couldn’t get down the stairs on his own. “I said, ‘Let me call 911, they’ll help you,’” said Haamid, who completed a fellowship in EMS after her training as an emergency physician.
Her father pushed back. He didn’t want his stomach pain to cost her a $1,000 ambulance ride. Haamid called anyway, even as he yelled at her not to. Once she realized the dispatcher heard yelling in the background, Haamid knew they’d send cops to check things out along with the ambulance.
Before she called 911, she’d wanted first responders to help her father out of the house. After the call, she wanted to get her father out of the house on her own, before police showed up and potentially endangered him further. “As a medical professional,” Haamid said, “I’m thinking, ‘Let’s get out of here before the police come.’”