The First Responders The black men from Pittsburgh who made up America’s original paramedic corps wanted to make history and save lives—starting with their own. By Kevin Hazzard The Atavist Magazine, No. 92 Kevin Hazzard’s work has appeared in Atlanta magazine, Men’s Journal, Creative Loafing, and The Washington Post. He also writes for television. A paramedic from 2004 to 2013, primarily at Grady Hospital in Atlanta, he is the author of A Thousand Naked Strangers: A Paramedic’s Wild Ride to the Edge and Back (Simon and Schuster, 2016).Editor: Jonah OglesDesigner: Ed JohnsonCopy Editor: Sean CooperFact Checker: Kate WheelingIllustrator: Marc AspinallPublished in June 2019. Design updated in 2021. Part I The riots that had begun in the heart of Pittsburgh’s Hill District on April 5, 1968, now seemed to rage beyond control. The world was all flames and broken glass, black soot and charred wood, food looted from stores, then dropped in egress. The day before, Martin Luther King Jr. had been assassinated in Memphis, Tennessee, and the calm that normally characterized the Hill, as the neighborhood was called, had given way to chaos. John Moon darted down Centre Avenue—terrified, exhilarated—as smoke poured into the air. Gangly and clean-shaven, his hair cut close to the scalp, Moon was a senior at Fifth Avenue High School. When word of the trouble reached them, Moon and his black classmates had walked out en masse. Now he ran the half-mile from school to the intersection of Centre and Crawford Street, the heart of the riots. Dusty shards of red brick from the destroyed facades of storefronts skittered across the asphalt and crunched under his shoes. Moon was a transplant—he’d only recently come to Pittsburgh from down south—and the riots caught him flat-footed. One minute he was cruising toward graduation, working nights and weekends at Shep’s hardware store and playing football in a small field near the Monongahela River. The next, a Molotov cocktail was sailing over his left shoulder and shattering a plate-glass window. He was in the belly of the civil rights movement. Moon was reticent by nature, a detached observer who mostly kept to himself. He was tall, with rigid posture. He spoke rarely and in a soft voice that was half an octave higher than you’d expect. His friends thought he was aloof, but he’d watched the national news footage of lunch-counter sit-ins, of police dogs and fire hoses, of freedom riders and black students walking into white schools for the first time, and he was just as angry and frustrated and hurt as his peers were. He may not have expected the riots on the Hill, but he understood why they happened. “It all built up and spun around in our heads,” Moon said. “Then there was an explosion.” Born in 1949 at Atlanta’s Grady Memorial Hospital, Moon lived the first eight years of his life just south of Georgia’s capital city with his parents, Clinton and Elzora, and his younger sister, June. In 1956, his mother died of complications from alcoholism. His father quickly realized that he couldn’t raise two young children alone and brought Moon and June to the Carrie Steele-Pitts Home, an orphanage in Northwest Atlanta. Clinton worked as a handyman, and when time allowed he visited the kids on weekends. But he soon grew ill—Moon never learned the specifics—and died. The children were well-fed and suitably clothed, sent to school and allowed time to play, but the orphanage staff never displayed the affection of a genuine family. There was no physical contact, no love, only the occasional toy or gift a child could call their own. “Everything belonged to the group, so when you got something, you didn’t let anyone touch it,” Moon said. One year, a relative sent him two dollars for his birthday. Rather than spend it, Moon tucked the money into an envelope that he kept nearby at all times. He slept with it under his pillow, hid it in his shoe when he showered, and carried it in his pocket when he went to school. “I said to myself, If you spend this, you’ll never have it again. So I just kept it,” he said. In the summer of 1963, the year he turned 14, Moon and his sister found themselves in a visiting room where an aunt they’d met only once, Mary Kelley, was waiting for them. The siblings could barely believe it. “You accept you’re not leaving,” Moon recalled of life at the orphanage. “There’s no hope of going anywhere, unless a miracle happens.” Kelley looked at each of them and asked if they wanted to come live with her in Pittsburgh. “It was shocking. The word adoption wasn’t in my vocabulary,” Moon said. It turned out that his father had maintained contact with relatives in Pennsylvania, who’d told Kelley that the kids needed a home. Kelley brought the children to her brick row house on Colwell Street, with a stoop and a white awning above the door. Overnight, Moon had a mother and a father, security and love. He later described the adjustment as “traumatic,” because it was all so new, so intimate. He couldn’t remember ever being hugged or kissed before arriving in Pittsburgh. The three-bedroom house was crowded with seven people, including two stepbrothers and a stepsister. Moon’s uncle—now his adoptive father—supported everyone on his meager salary from a steel mill. Each night, Moon washed and folded his clothes so that he could wear them again the next day. It wasn’t a perfect life, but it was better than living on public assistance in a crumbling tenement, like some of his classmates at Fifth Avenue High did. Wedged between downtown and the affluent, predominantly white Oakland neighborhood, the Hill had for 200 years served as the heart of black Pittsburgh. It once boasted a Negro League baseball team, with Satchel Paige on the mound; Duke Ellington and Louis Armstrong played in the local jazz bars; and there was a black-owned newspaper, the Pittsburgh Courier, with national syndication. Then, in 1956, the future arrived with the heavy crash of a wrecking ball. As part of an effort to modernize, the city plowed through a large swath of the Hill to build a civic center with a vast, usually empty parking lot. The city razed 1,300 homes and businesses and displaced 8,000 people. Gutted and stripped, what remained of the Hill slumped into poverty. Crime arrived, and with it the stigma of being a black man who lived in the neighborhood and surely would amount to no good. This was the environment that shaped Moon. He’d tried to ignore it but couldn’t escape the fact that the outside world saw him, simply because of where he lived, as an “unemployable,” a term used in the local press to describe residents of the neighborhood. “I really resented that label. It meant you were of no use,” Moon said. Before the riots, Moon hoped that hard work and maybe a little luck would give him a shot at a good job, a house of his own, a life just a bit better than the one his adoptive parents had. After the fires of April 1968, as his neighbors swept up the ashes, he worried that hope didn’t apply to him. He saw how the city and the National Guard let the Hill burn. “As long as it didn’t affect the white or business areas, they stood by,” he said. “They didn’t care why we were rioting. They just kept it penned in.” A few months later, with graduation behind him, Moon followed his adoptive father into the steel mills. He got a job loading massive metal coils onto railcars and sometimes operated a blast furnace. He worked six or seven days a week and spent his money on an expansive wardrobe. In his spare time, he strutted down the sidewalk in khaki pants and an alpaca sweater, his shoes buffed to a mirror shine. Gone was the kid who’d worn the same clothes every day. At work he was in awe of the equipment and the blisteringly hot liquid metal, but he was unimpressed with the management, which was exclusively white. Sometimes there were layoffs due to a lack of work, and he’d find himself with nothing to do. The message was clear: If he wanted to get ahead, he’d have to go elsewhere. “So I left,” Moon said. A relative suggested that he get a job as an orderly at Presbyterian-University Hospital, part of the University of Pittsburgh. In 1969, he completed a brief course on the basics of moving and washing patients, making beds, and following hospital policy. It wasn’t flashy work, but it was stable, and a lot less dangerous than the steel mill. “I could either use my head or my back,” Moon said. “I chose my head.” He soon realized that he enjoyed caring for people; it revealed empathy and compassion he hadn’t known he possessed. As he transported patients, they would peer up at him, their eyes projecting loneliness, fear, vulnerability. “I know what it’s like,” Moon said. “When I looked at those patients, I could feel for them.” He wanted to do more—to heal, to save, to be the miracle that unexpectedly entered a stranger’s life. During the 1968 riots, he’d seen where hopelessness led. He didn’t want to feel that way—and he didn’t want anyone else to, either. One night in 1970, while walking in a hospital hallway, Moon saw two black men in white tunics pushing an empty stretcher. He’d never seen the men or their uniforms, which were affixed with patches reading “Freedom House Paramedics.” He stopped walking to get a better look as they passed by but caught only a glimpse before they were gone, off to whatever job they were doing. It looked important, far more so than what he did as an orderly. Later he saw the men again, this time rushing by with a stretcher loaded with a howling patient. Moon spun and watched as one of them flagged down a white doctor with a casual flick of the wrist—and the doctor actually followed. Just as fast as they’d come into the hospital, the men disappeared through a set of swinging doors. Moon still didn’t know who they were, where they’d come from, or what exactly their job was. He knew only that here were two men who carried themselves as if they knew something no one else did. Cockiness isn’t uncommon in a hospital, as Moon well knew, but here was an attitude of complete confidence coming from someone who was black—from someone who looked just like him. Whatever a paramedic was, that’s what Moon wanted to be. Peter Safar Part II John Moon wasn’t the only one who didn’t know what a paramedic was. Most people in America didn’t. Today the role is clearly defined: A paramedic is certified to practice advanced emergency medical care outside a hospital setting. They’re the people who shock hearts back into beating, insert breathing tubes into tracheas, and deliver pharmaceuticals intravenously whenever and wherever a patient is in need. Until the mid-1960s, however, the field of emergency medical services, or EMS, didn’t formally exist. Training was minimal; there were no regulations to abide by. Emergency care was mostly a transportation industry, focused on getting patients to hospitals, and it was dominated by two groups: funeral homes and police departments. Call the local authorities for help and you’d likely get morticians in a hearse or cops in a paddy wagon. If you received any treatment en route to the hospital—and most likely you did not—it wouldn’t be very good. At best, one of the people helping may have taken a first-aid course. At worst, you’d ride alone in the back, hoping, if you were conscious, that you’d survive. Standards for emergency care were so low that, in 1966, the federal government released a study reporting that a person was more likely to die from a highway accident in Kansas than from a gunshot wound in Vietnam. In a Southeast Asian rice paddy, a soldier could at least expect a medic to arrive and provide care where he’d fallen. An IV, bandages, pain meds—you could get them in the jungle, but not in an American city. Certainly not in a place like Pittsburgh, where the police ran the ambulance service and where calls to improve it, or to offer an alternative, had long been ignored. It took a very public death to open the door for change. On the night of November 4, 1966, David Lawrence, a former mayor of Pittsburgh who’d also served as governor of Pennsylvania, collapsed on stage at a campaign rally. Someone called an ambulance and the police arrived. They put Lawrence onto a crude stretcher, loaded him into a paddy wagon, and drove ten minutes to Presbyterian-University Hospital, where he was met by Dr. Peter Safar, a wiry Austrian anesthesiologist. Lawrence had suffered a massive heart attack and showed no brain activity. His family ultimately decided to take him off life support. Over the following weeks, as the city grieved, Dr. Safar stewed. The police had been poorly equipped. Safar concluded that, had they been driving an ambulance designed to enable crews to provide critical care, Lawrence might still be alive. CPR training could have helped, too. Safar would know. He’d all but invented it. Born in Vienna in 1924, Safar was drafted into Adolf Hitler’s army despite his Jewish ancestry. In 1943, he was nearly sent to fight on the Eastern Front; he escaped deployment by smearing himself with an ointment that inflamed his eczema. He began studying medicine and emigrated to the United States in 1949. He settled in Baltimore, where he practiced medicine and studied resuscitation. Safar discovered that adding direct ventilation—now called mouth-to-mouth—to the already established practice of chest compressions exponentially increased the chance of survival for a patient in cardiac arrest. Though Safar is now hailed as the father of CPR, the medical establishment initially disagreed with his notion that the method could, maybe even should, be taught to private citizens. To prove them wrong, Safar paralyzed volunteers with curare, the compound used by Amazonian tribes to make poison-tipped arrows, and trained Boy Scouts kept them breathing using only mouth-to-mouth. Gradually, across America, ordinary people began using CPR. In Pittsburgh, where Safar had moved in 1961, Lawrence’s death exacerbated the pain of personal heartbreak. In June 1966, Safar’s 11-year-old daughter Elizabeth suffered a severe asthma attack and stopped breathing. When Safar arrived at the hospital to take over his daughter’s care, he was able to restart her heart, but she never regained consciousness. Elizabeth, it turned out, had received no treatment en route to the hospital, and prolonged lack of oxygen led to brain death. The tragedy was a lasting source of regret for Safar; according to his son, it “cast a shadow over the family.” It also drove him to double down on his belief that providing medical care outside hospitals was critical. Some sick and injured patients simply couldn’t wait; the process of saving them had to start immediately. Shortly after Lawrence’s death, Safar heard that Phil Hallen, a progressive activist and president of the Maurice Falk Medical Fund, a local philanthropy, had proposed the establishment of a city ambulance service, manned by specially trained technicians called paramedics. Safar invited Hallen to his office and unleashed a torrent of ideas. What if ambulances weren’t just crowded, repurposed cargo spaces but mobile intensive-care units, where paramedics could use portable cardiac monitors, administer medication, and perform CPR? Safar described how tall and wide ambulances should be, and how to position the seats inside to maximize patient care. He talked about installing automated suction units that could help clear blood and vomit from the mouth and lungs of an unconscious patient. Together the two men hashed out a plan: Hallen would raise the money, Safar would contribute his medical expertise, and together they would design advanced ambulances and teach paramedics to provide care on the scene of an accident or emergency. It would be a pioneering medical effort, and Hallen, who was white, suggested another first. The Falk Fund was committed to mitigating racism, and Hallen wanted to staff the service with young black men from the Hill. He hoped that empowering individuals long deemed unemployable would be a source of pride in the black community, a symbol of equality, and a signal that bigoted notions about the black people of Pittsburgh standing in their own way were nonsense. To help with recruitment, Hallen and Safar partnered with an organization called Freedom House Enterprises, a nonprofit dedicated to establishing and supporting black-run businesses in the city. Freedom House handled staffing for the fledgling ambulance service and recruited the first class of paramedics, including Vietnam veterans and men with criminal records. Though some of the recruits had an idea of what they’d signed up for, many were all but shanghaied off the streets of the Hill just hours before the classes that Safar had designed were scheduled to begin—Freedom House needed a set number of students to fully staff the service. Once they learned more about the opportunity, most of the impromptu recruits threw themselves into training. After undergoing a battery of tests, including psychological evaluations and interviews with various medical professionals, the recruits embarked on Safar’s 32-week paramedic course, the first of its kind in the world. They learned about anatomy, physiology, CPR, advanced first aid, nursing, and even defensive driving—a must when piloting an ambulance. They completed internships at Pittsburgh’s morgue, with anesthesiologists in surgical settings, and in emergency rooms. Sometimes they were mistaken for orderlies and asked to mop the floor. Call the local authorities for help and you’d likely get morticians in a hearse or cops in a paddy wagon. If you received any treatment en route to the hospital—and most likely you did not—it wouldn’t be very good. In the first two years, nearly 50 recruits completed the program and began working from a base of operations at Presbyterian-University Hospital. The medics of Freedom House—the name stuck—formally hit the streets in July 1968, a few months after the riots that erupted in the wake of King’s assassination. They served the Hill, Oakland, and downtown, operating two ambulances. In its first year, Freedom House responded to nearly 6,000 calls and was credited with saving more than 200 people from heart attacks, gunshot wounds, stabbings, and overdoses. In nearly every case, the paramedics arrived in less than ten minutes; often they got there much faster. Fewer than 2 percent of Freedom House’s patients died before they reached the hospital. The city’s safety director called the service “excellent.” Still, it was forced to beg for public funding. “It was tricky, because nobody understood what we were doing,” Hallen said. Pittsburgh offered some money, but not enough to keep the service running, so Hallen turned to the private sector. When a contact at the Ford Foundation expressed confusion in a phone call about what Freedom House was, Hallen packed a few trainees into one of the ambulances, drove north to the foundation’s New York City office, and parked just outside its 43rd Street entrance. All day people climbed inside the ambulance and looked around. The trainees gave a CPR lesson. The road trip proved worthwhile: Freedom House got the money Hallen wanted. John Moon was a lot like the curious New Yorkers. After spotting the paramedics for the first time, he watched them carefully whenever he saw them at the hospital—smoking cigarettes, joking with each other, filling out official-looking paperwork. He noted how, when their radios crackled, the men hopped into their ambulances and disappeared, sometimes into the dark, uncertain night. “I was in awe of them,” Moon said. “I had to join. It was almost like a calling.” It took a few months, but in 1971 he finally worked up the courage to ask about joining their ranks. Sitting in an office chair across from Freedom House’s operations manager, Moon explained why he was there. “Since I first saw you guys,” he said, “it’s all I’ve wanted to be.” “A paramedic,” the operations manager replied. Moon blinked. He still didn’t know the word. “I don’t know. I guess, yeah. I’ve been an orderly for a few years now and—” The man cut him off. “You don’t have the qualifications,” he said. “There’s no applying. You have to earn your way in.” The man stood and shook Moon’s hand. “Go take the course,” he said. “Then we’ll talk.” That’s how Moon found himself enrolled in emergency-medicine classes. They kicked his ass, but he didn’t care. “I had a specific goal in mind—to join Freedom House,” he said. When he finished the training and was finally given a white uniform, it was better than any alpaca sweater. “It was a very intense moment,” he said of slipping into the tunic for the first time. “A proud one. Like putting on a $500 suit. From that moment, taking care of people wasn’t something I did. It became who I was.” Twelve hours after donning the uniform, Moon was speeding through Pittsburgh’s streets in the front seat of a Freedom House ambulance as a voice on the dispatch radio sounded in his ear, firing off details about a man who’d overdosed on heroin and was lying unconscious in the street. Behind the ambulance’s wheel was George McCary, who’d joined Freedom House in its earliest days—back in 1968, when his grandmother had threatened to kick him out of the house if he didn’t get a job. McCary was thick, with a rolling gait and an easy smile. There was nothing easy about Moon that day. “I was terrified,” he said. McCary screeched to a halt outside a darkened building. As he grabbed his equipment, all Moon could see were the patient’s outstretched legs on the sidewalk; the man was surrounded by a crowd of anxious onlookers. McCary, who seemed to know everybody at the scene, quickly began to distract them. Moon found himself alone with the man on the ground. He dropped to his knees, checked for breathing, and found none. With shaking hands, he tore open the packaging of a reusable ventilator. Moon gave the patient a quick puff of air and saw his chest rise as his lungs filled. Moon looked over his shoulder. There was McCary—still talking, still smiling, keeping the crowd busy. Moon realized it was all part of the job. “We worked together for three years,” Moon later said. “I let him handle the crowds. He was happy-go-lucky. He knew everybody. He was like the mayor.” After Moon pumped a few more breaths into the patient, he and McCary put the man on a stretcher and hurried him to the ambulance. Moon used the electric suction system—the kind Safar had dreamed of putting in ambulances—to clear the man’s airway. By the time they arrived at the hospital, the patient, who only minutes before had been limp, was very much alive. He was laughing with McCary. Moon was on his way. So was Freedom House. The medics had proven themselves, and Safar was eager to ramp up their skill set and expand the service. He wanted it to cover all of Pittsburgh, and the county, too. With a note of optimism, Safar wrote in a letter to the city, “The time for action has come.” John Moon Part III Barreling down Fifth Avenue, the ambulance whooshed past vacant lots and houses with boarded-up windows. It was a grime-caked Chevy G20 van, 40,000 miles past its prime and riding on a set of bald whitewall tires. A piece of silver-colored trim had broken off, leaving a lonely trail of holes where rivets should have been. Its grill was punched in and hot to the touch. Painted on the van’s side were the words “Freedom House Ambulance.” McCary drove with one hand as he ate a sandwich. Beside him sat Moon. It was 1974, and in the three years since joining Freedom House, Moon had grown an afro and a beard, though neither were full yet. He wore square-framed silver glasses that sat stylishly on his nose. As the ambulance pulled onto the Presbyterian-University Hospital campus and into its usual parking spot, the engine shuddered and then stalled. Moon sighed and flung open his door, which let out an aggrieved moan. Despite its early successes, Freedom House had struggled. It was undermanned and underfunded. The paramedics still weren’t working across the whole city. Pittsburgh would allow them to serve only those neighborhoods they’d started out in, and the service ran the majority of its calls in the Hill—a fact that elicited complicated emotions among the paramedics. They were bringing medical care to people in need, many of whom they’d grown up or gone to school with. Moon and the other paramedics had escaped the cycle of violence, drugs, and poverty that wracked the Hill, but now they were present for the darkest, sometimes final moments of people who had not. Freedom House charged $25 to $50 per run but made very few collections; people struggling to buy daily necessities tended to ignore ambulance bills, and the paramedics weren’t about to chase them down. Management had to decide where to spend money. Or rather, where not to spend it. Ambulance repair was last on the priority list. Brakes and steering regularly locked up. Doors fell off their hinges. One crew reported that the bolts securing the passenger seat had jiggled loose; the seat, along with its occupant, had toppled over. At least once, an engine caught fire. A bigger problem than unpaid bills was dwindling municipal support. Initially, the city had agreed to contribute $100,000 a year and to direct emergency calls that came into the police from the three designated neighborhoods to Freedom House. Then, in 1970, a new mayor took office. Pete Flaherty was tall and broad shouldered, the son of Irish immigrants. As a city councilman, he challenged his own party’s mayoral candidate and broke from the Democratic machine that had crowned every mayor since the Great Depression. Labeling himself Nobody’s Boy, the 45-year-old was a small-government fiscal conservative who lowered taxes and trimmed the city’s payroll. He strongly opposed public-private partnerships like Freedom House. Flaherty halved the city’s contribution to the paramedics’ budget, even as Freedom House’s operating costs rose. Making matters worse, the city was chronically late delivering payments. In 1973, Freedom House received no municipal money—funds that were supposed to be paid out monthly—until November. Flaherty turned down offers for Freedom House to expand across the city, including into wealthier, whiter neighborhoods, where bill collection wouldn’t be such a challenge. The police already had those areas covered, the mayor said. Moon and the other paramedics had escaped the cycle of violence, drugs, and poverty that wracked the Hill, but now they were present for the darkest, sometimes final moments of people who had not. Safar and his staff presented data showing that the police provided subpar emergency care 62 percent of the time, compared with 11 percent for Freedom House. He blamed the city’s paddy wagons and the suburbs’ funeral-home hearses for 1,200 preventable deaths each year. The Pittsburgh Post-Gazette, where journalist Dolores Frederick doggedly covered the ambulance wars, reported that the purchase price of Freedom House’s ambulances was $7,000 and that the paramedics made $153 per week. Police wagons cost $17,000—though, to be fair, they were used for multiple purposes—and the cops who drove them made $230 per week. Op-eds in the Post-Gazette accused Flaherty of trying to placate the police union. In his memoirs, Safar would blame “racial prejudices with white police officers eager to maintain control of ambulances city-wide” for city hall’s treatment of Freedom House. Flaherty’s record on race was complex: Though he disbanded police tactical squads, whose reported brutality upset the black community, he also opposed school busing. Safar’s take seemed right to Moon. “I don’t know if Flaherty was racist,” he said, “or just head of a racist system.” One morning, Moon walked into Freedom House’s glass-walled station, and the operations manager told him that there was a new policy: no more sirens when driving downtown. “What?” Moon asked, incredulous. “Mayor banned ’em. You get to the edge of downtown, turn ’em off.” “For what?” “They’re too loud,” the manager said dryly. “The noise is bothering the business community.” Without use of the sirens, traffic wouldn’t move aside for the ambulances, which meant that police officers, who were still allowed to use theirs, could beat the paramedics to patients in need. And even when the paramedics did get to an emergency scene first, it didn’t always go well. On one run, Moon entered a large office building with a cardiac monitor, oxygen, and a jump kit on a stretcher, which he crammed into a small elevator. On the seventh floor, he followed a series of narrow hallways past sprawling offices until he found his patient sitting in a conference room, leaning forward, clasping her chest, most likely having a heart attack. The hope that flashed in her eyes at the sound of his approach disappeared when she registered Moon. She was white; he was black. She said she didn’t want him to touch her. Moon had heard this before. He got down on one knee, looked into her eyes, and in his soft voice said, “Without care you’re going to die. And we’re the only ones here.” The woman acquiesced. Sometimes, though, patients didn’t. Other cities saw the success of Freedom House’s model and copied it, among them Miami, Los Angeles, and Jacksonville, Florida. Even Flaherty couldn’t deny that medical history was on Freedom House’s side. In 1974, the mayor announced a plan to institute a citywide emergency-care system, complete with state-of-the-art ambulances staffed by paramedics. Rather than absorb the groundbreaking company of black paramedics, however, Flaherty proposed training police officers. Freedom House would remain funded through the end of the year. After that the money would be gone for good. Moon tried to ignore the politics. “I knew it was going on, but I was focused on the patients,” he said. “That’s what mattered.” Some paramedics were angry. “If this was a mostly white operation,” Eugene Key brooded at the time, “I don’t think this would be happening.” The men weren’t alone. Some public officials confronted Flaherty. “We must continue the Freedom House ambulance service and hopefully expand it,” city council member Eugene DePasquale wrote in an op-ed, adding that asking police to do more work “would be stretching the department too thin.” Flaherty retreated in the face of pressure, but only a step. He agreed to fund Freedom House for an additional year. Then, he said, the police would take over for good, running a half-dozen brand-new vehicles the press dubbed “super ambulances.” Safar was close to giving up. He even recommended in a letter to the Freedom House board that the service stop accepting money and be “permitted to die a dignified death.” However, in the fall of 1974, just as the project seemed to be on its last leg, Safar began serving on a committee convened by President Gerald Ford to coordinate the development of national emergency-care standards. The committee explored the idea of giving a grant to a single paramedic service, which would serve as a testing ground and pilot program for the rest of the country. As one of only five people on the committee, Safar would’ve known about the grant. He may have reasoned that if Freedom House won it, the service would receive enough recognition to persuade Flaherty not to shut it down. There was a problem, though: Freedom House had been fighting to keep the lights on while Safar simultaneously ran the anesthesiology department at the University of Pittsburgh, so the paramedics’ proficiency level hadn’t advanced far beyond their initial training. They couldn’t yet intubate patients, for instance, and lacking consistent medical supervision, their discipline and skills were slipping. Safar knew that winning the grant would require tough, tireless leadership that he couldn’t provide. Yet every doctor he asked to train and oversee the medics said no. So he turned to a stranger. Through the hospital grapevine, he heard that a medical fellow was curious about ambulances. Her name was Nancy Caroline, and though she was young, her résumé was impressive. She’d finished high school early and attended Harvard’s prestigious all-female affiliate, Radcliffe College, graduating summa cum laude in 1966. Amid the rigors of medical school, she’d found time to write poetry and make a surrealist film; she’d also taken a brief sabbatical to study under Noam Chomsky at the University of California at Berkeley. Safar immediately dispatched three of his senior staff at the hospital to sell the 31-year-old with straight brown hair and an electric smile on the idea of Freedom House. Caroline was in the ICU checking on patients when the doctors approached her. “Dr. Safar has a challenging job for you,” one of them said. Caroline paused before answering. “I already have one,” she said. Safar wanted her to serve as the new medical director of Freedom House, the doctors explained. Caroline shifted her weight. She knew of Safar. Every young doctor in the hospital was simultaneously awed and intimidated by the harried physician who breezed by in his white jacket and threadbare slacks. But she’d met him only once, for just a second, and she’d never heard of the organization Safar’s staff were describing. “What’s Freedom House?” she asked. “They’re a group of EMTs.” Caroline knitted her brow. “What’s an EMT?” One of the doctors thrust a bundle of documents into her hands. “You’ll love it,” he said. He was right, even if he didn’t realize it. Caroline was restless by nature and hadn’t found her professional groove in Pittsburgh. She lived in a small apartment and kept a diary documenting her dissatisfaction. “Rain the interminable,” she wrote one day, describing Pittsburgh’s bleak weather. “The endless gray saps my energies, replacing them with a … longing … without an objective.” She wrote of wanting “meaning to overtake my existence.” As her brother Peter once said, Caroline was also “a born contrarian.” She relished a challenge. “The best way to get her to do something is to tell her she can’t,” he said. The paperwork Safar’s staffer gave Caroline described nearly seven years of Freedom House’s complicated, acrimonious history. As she pored over the pages, she was impressed by the program’s promise and shocked by the city’s unrelenting opposition. She finished reading and dashed off a memo to Safar. She asked how much of her time the job of medical director would take and what it would pay, and she said that she didn’t want to be a paper pusher. She wanted to treat patients, “be that in an ER, helicopter, truck, bicycle, or whatever.” Safar assured her she would be doing important, hands-on work. Caroline accepted. It was December 1974, and when she told fellow doctors the news, they shook their heads apologetically. “It’s really not as bad as it seems,” one told her. Nancy Caroline Part IV January 1975 arrived with an icy, stinging wind. Caroline’s first encounter with Freedom House was painful, too, laden with bias and suspicion. Writing about it later, she described “three very imposing, bearded, machismo characters who might easily have passed for the Black Mafia” appearing in her office door. The men, supervisors of the emergency service, had come to present their grievances to the new boss. Caroline was so intimidated that she didn’t hear a word they said. She simply nodded, her mind reeling, until they left. The paramedics’ reaction to Caroline was little better. When the operations manager announced her hiring, the men were incredulous. That a woman—a white woman—would be in charge didn’t make sense or seem fair. What could she teach them? They wondered if she could possibly understand the racism and condescension that stood in Freedom House’s way. Her goal was to prepare Freedom House to win the federal grant that would allow it to make medical history and hopefully save the service from closure. She listened to the paramedics’ radio chatter, read the reports the men wrote after each call, and ventured into the field with them. What she found was chaos. Each paramedic seemed to operate according to instinct rather than any common standard. One day, Caroline joined Moon when he brought a patient into the emergency room. While giving his report to a nurse, he struggled to explain the medical history, the findings, and his actions. After a few minutes, the doctor just walked away. “It was humiliating,” Moon said. Caroline knew that communication mattered; fairly or not, medical professionals took people seriously only if they used the right words and cadence. Caroline began what she later called an Orwellian reign of terror, keeping eyes and ears on everything the paramedics did and pushing them to improve. “We were all scared of her,” Moon said. “She was everywhere. Anything you did, you’d have to explain to her.” Caroline used the service’s radio to insert herself into every emergency call. There wasn’t a single case of Freedom House deploying to the Hill in early 1975 that wasn’t haunted by Caroline’s disembodied voice. Caroline instituted weekly debriefings where medics stood before their peers to have every detail of a case questioned and reviewed. “All you knew was that they were going to take one of your calls and critique it,” Moon said. “But you had no idea which one it would be. You had to be ready for anything.” In one of the meetings, Caroline selected a call in which Moon responded to a patient with chest pain. The questions came in a flurry: Why hadn’t he double-checked the patient’s vitals? How much oxygen had Moon given? Had he checked if the neck veins were distended? No? Why not? What did the EKG read? “It required only a month or two to establish the necessary paranoia,” Caroline later wrote. She wasn’t always so tough. On one occasion, Moon recalled, she noticed him staring intently at an EKG monitor—those squiggles had always vexed him, and he couldn’t get a read on them as fast as he wanted. Caroline gave him a quick, thorough set of pointers. “The simplicity of her explanation was amazing,” Moon said. He was soon able to distinguish between first-, second- and third-degree heart blockages at a glance. When Caroline wasn’t checking the paramedics’ work or leading training in advanced life support—the kinds of skills that would help the service win the grant—she was begging Freedom House’s board of directors for new equipment or doing rounds at Pitt’s hospital, where she was technically still a fellow. “Too many cigarettes,” she wrote in her diary. “Too little sleep. A state of strange lucidity. The mind outdistances itself and is forever doubling back to pick up stray thoughts.” Safar wrote to Caroline, reminding her that she’d volunteered for the job, which was now consuming her to the point that she often slept on a cot at Freedom House’s headquarters. “Certain of your remarks,” she fired back, “warrant comment.” Most disturbing, she wrote, was the “implication that I was given a position for which others were clamoring.… I took a job no one else wanted.” Caroline struggled to connect with the paramedics. They didn’t know, for instance, that 1975 had started with a personal loss. Caroline had received a call about her fiancé, who lived in Boston. He’d been found dead in his apartment near Massachusetts General Hospital. The death was ruled a suicide, though Caroline had trouble believing it. This “massive dose of human tragedy,” Caroline later wrote, left her “entirely fed up and disillusioned with mankind.” She felt lost and alone, in need of salvation. She found something like it one day around lunchtime, just as everyone at Freedom House’s station was getting hungry. A man was having a heart attack, and before the dispatcher was even done talking, Caroline was up and out the door. She was followed by paramedics. They rocketed through the Hill in an ambulance and pulled up to a crowd of cops and bystanders, but no patient. Someone pointed to an open manhole. The man was underground. A cop, smirking, said, “It’s a perfect job for Freedom House.” Whatever flashed in the paramedics’ eyes—hurt, anger—Caroline registered it. She faced them. “Ready?” she asked. Walt Brown, one of the responders that day, spread his arms wide: “After you, doc.” One by one, the group squeezed through the hole and descended from the mild sunshine of a winter’s day to the dank gloom of a sewer. They found their patient ten yards away, in full cardiac arrest. Caroline started ventilating, and Brown administered compressions. The man needed to have his heart shocked. “Stand very clear,” Caroline instructed the paramedics as she placed the paddles on the patient’s chest; there was ankle-deep water beneath them. They nervously held their breath as Brown hit the shock button. The man arced and stiffened, then came to rest. The group turned to the cardiac monitor they’d brought with them. His heart was beating. Freedom House had brought a man back to life deep beneath the city’s streets, working in the dim halo of lamplight. Now they had to get him aboveground. They put him on a portable stretcher to haul him straight up through the manhole, but he wouldn’t fit. A city sewage worker who’d led the paramedics to the patient said he thought there was another, larger hole not far away. Off they went, Caroline later wrote, “a little band of pilgrims wandering through the bowels” of Pittsburgh—the city employee up front with a lamp, Caroline behind him holding the medical equipment, then Walt Brown and George McCary carrying the stretcher and the patient, who was now breathing on his own. They walked for several blocks; they got lost, they got wet. Eventually, they made their way back to the world, blinking in the sun. The call complete, McCary looked at Caroline. They hadn’t had their lunch. “You hungry?” he asked, carefree as ever. Brown slowly turned his head to take in what was happening. The men didn’t normally eat with the boss. “I know this place,” McCary continued, “biggest fish sandwiches in Pittsburgh.” There was a silence that seemed to stretch forever. Then, nodding, Caroline said, “I’d eat one of those.” “You’re gonna like it,” McCary said, bobbing his head. “Place is legit.” Red lights bounced off the tenement’s cracked walls and gave Bedford Avenue, crowded with people, the feel of a disco gone wrong. Half a block away, someone was whistling a slow tune. Caroline emerged from the ambulance, joining Moon at the bottom of the steps leading into a building. She followed his gaze to the ground, where a small dark puddle had pooled. “Blood?” Caroline asked. Moon nodded. “Looks like it.” The blood led them up the steps, then disappeared behind a door, into the dark recesses of an apartment. They followed it inside and to the kitchen, which smelled of garbage. A bare lightbulb reflected off broken windows and cast shadows across rotting timbers. Children ran in and out of the room as an old woman shrieked. In a corner, a shirtless drunk man smoked a cigarette, staring idly at another man who lay unconscious on the floor in a widening pool of his own blood. The old woman stammered that the man had been stabbed. Moon dropped to his knees to cut open the patient’s pants. Blood spurted from his thigh, covering Moon’s hands and soaking the white cuffs of his jacket. Moon bandaged the wound, then slipped on military anti-shock trousers; once inflated, they compressed to stabilize a fracture or stem a hemorrhage. The bleeding stopped. Back in the ambulance, Moon started an IV, and the man recovered consciousness enough to say that his girlfriend had hit him in the head with a bat before stabbing him. Moon looked behind the man’s ear and found bruising, the telltale sign of a basilar skull fracture. His stomach sank—in the midst of all the blood in the apartment, he hadn’t assessed the man’s body to identify other possible injuries. Moon looked at Caroline, who shot him a smile of encouragement. He was doing well, making progress. Moon presented a perfect report on what he’d found in the field—including an EKG reading. The admitting doctor, a white man, stood in stunned silence as Moon walked away. It was mid-February 1975, and Freedom House’s transformation was in full swing. Caroline had followed the paramedic crews, and she knew how hard they worked. She trusted them, and they’d begun to trust her, too. “She became one of us,” Moon said. Caroline suspected that the cops were withholding emergency calls in Freedom House’s coverage area, so she programmed the police frequency into the service’s radio. When Moon or another paramedic heard a call come in—a low squawk emanating across the airwaves—he’d sprint out the door to an ambulance, turn the key, yank the gear stick, and stomp the gas. The vans didn’t have power steering, so the drivers had to wrestle them up and down Pittsburgh’s hills, shoulder muscles screaming all the way. The brakes barely functioned and had to be pumped repeatedly. After quaking to a stop, the men would jump out, grab their equipment, and hope to reach the patient just as the police—bewildered, pissed—arrived on the scene. Moon said he’d flash his most apologetic smile and say with a shrug, “Happened to be in the neighborhood.” Under Caroline’s leadership, Moon and the other paramedics dived into more than 200 hours of lectures, demonstrations, and practical sessions in hospital units and labs. Doctors and nurses at Pitt got used to seeing a brash young woman trailed by a cluster of black men breezing through the halls. One afternoon, Moon and Caroline delivered a patient from a call together, and Moon presented a perfect report on what he’d found in the field—including an EKG reading. The admitting doctor, a white man, stood in stunned silence as Moon walked away. The paramedics practiced intubation on mannequins and dead dogs. If they could master that skill, it would be a game changer. Moon was the first among them to try his hand at a real patient. He was summoned one day to a hospital operating room; he felt a knot form in his stomach as his mouth went dry and his hands became damp with perspiration. A sedated patient, prepped for surgery, lay on a gurney. Safar stood nearby. Moon’s eyes darted to the steel surgical tray where the intubation equipment was neatly laid out, waiting for him. “You have 30 seconds to intubate,” Safar said. “Go.” Moon tilted the patient’s head back and grasped the cold metal of the laryngoscope in his left hand. He slipped its curved, blunt blade into the patient’s mouth to lift the tongue and get a view of the vocal cords—the gateway to the trachea. He couldn’t see them. The clock was ticking. Safar was watching. If Moon got this wrong, he could insert the breathing tube into the esophagus, dangerously inflating the patient’s stomach. Beads of sweat formed on Moon’s neck. He caught sight of the cords. Not daring to take his eyes off them, he reached for the next piece of equipment—an endotracheal tube—with his right hand. He slipped it into the patient’s mouth and passed it between the vocal cords. Then he removed the laryngoscope and looked up. A second doctor pumped air into the patient’s chest while Safar checked to make sure the patient’s lungs inflated. The tube was in place. It had taken Moon less than 20 seconds to get it there. The paramedics had heard the rumors circulating around Pittsburgh. That they were running craps games in the back of the ambulances. That they were selling drugs. That $25,000 had gone missing from Freedom House’s budget. “Twenty-five grand?” Moon spat the first time he heard that one. “That’s like a million dollars around here. This place would go under immediately.” The rumors might have been ridiculous, but they didn’t surprise Moon. “Freedom House was successful,” he said. “You look inside the vehicle, you see who’s in there, and you discredit the organization.” The men and Caroline all hoped that validation was forthcoming—the kind that would silence critics once and for all. To show off Freedom House’s advanced skills and unflagging work ethic, Caroline decided that, as part of an international symposium on emergency medicine that took place in Pittsburgh each year, the paramedics would conduct a disaster drill. She wanted some of the best doctors in the world to see for themselves what Freedom House was capable of. It would go a long way toward the organization winning the coveted federal grant, which would be announced in July 1975. Bigger cities were vying for the money, too. Freedom House needed to put on a show. It was a hasty decision, and Caroline immediately regretted it. She drew up a detailed script for staging a car crash, choreographing where to place fake patients in various states of emergency. Caroline had trouble getting city permits to stage the drill, convincing the police to provide crowd control, securing wrecked vehicles to set the scene, and then finding someone to tow them to the site. Worst of all, perhaps, was the pressure: If Freedom House failed—if the men were humiliated at the symposium—it would likely be shuttered before the year was out. The rehearsals went terribly. The paramedics were accustomed to real emergencies, to improvisation, not to memorizing what amounted to a detailed dance. They performed the wrong care on patients, used the wrong equipment. The men and Caroline were certain they were screwed. May 9 broke warm and clear. By noon, with the sun directly overhead, the temperature was in the upper seventies. A light wind blew. It was silent outside the downtown Hilton except for the shuffle of feet. Before an expectant crowd of nearly 100 people, spread out across a city block, was a collage of wrecked vehicles and 14 critically injured patients. Caroline felt frozen in place, terrified, as she watched the drill begin. Feedback squealed through speakers as one of her colleagues stepped forward and read from his script. After describing the horrific accident before the crowd, the doctor presented each of the victims’ injuries in excruciating detail—where and how they were broken open and bleeding, who was likely to die without immediate and expert care. “If this happens in your town,” he read, “would your community be able to respond?” The distant wail of a siren split the air. The sound grew closer, and a Freedom House ambulance rounded the corner. Two paramedics sprang out. After assessing the scene, they called four additional units. At the five-minute mark, Moon threw his truck into park and hit the street running. From the corner of his eye he could see the crowd. He reached the patient he was supposed to treat and quickly dropped to his knees. Caroline watched as, like Moon, each paramedic hit their mark. Patients were triaged into four categories: critical, urgent, non-urgent, and deceased. In about 20 minutes, more than a dozen people were treated and transported away. For the audience, it was like glimpsing the future—one in which trained technicians dispatched into the field handled even complicated medical crises with speed, skill, and proficiency. If medics everywhere were able to do exactly this, how many lives could be saved? According to James O. Page, a pioneer and historian of emergency medicine, word quickly spread that Freedom House paramedics were “the most skilled and sophisticated in the nation.” After the drill, Caroline sat by herself and smoked a cigarette. She felt victorious but frazzled. She watched as the crowd of doctors and experts fawned over the black paramedics from the Hill. “I found myself among these genuine, warm human beings,” she later wrote in her diary. “I have chastised them, praised them, berated them, laughed with them, cried with them. I have met their wives and husbands and parents and children. They have kept me alive.” Now, it appeared, she’d returned the favor. A few weeks after the symposium, Freedom House won the federal grant. It would develop the first nationally recognized standards for emergency training and medical practice by paramedics. “We did something no one thought we could,” Moon said. “To have jumped those barriers, proved everyone wrong? Nobody could take away what we did or the pride we had.” Surely, he thought, Pittsburgh would agree. Part V Moon was wrong. The grant would be processed through city hall, and despite its huge strides, Mayor Flaherty still saw Freedom House as expendable. That summer he announced that Pittsburgh would develop a citywide paramedic service manned by civilian medics, not the police. Freedom House wasn’t part of the plan. The city would terminate funding and the agreement to direct calls to the service before the end of 1975. Pittsburgh’s new paramedic force would be built from scratch. The city began hiring replacements, all of whom were white. Caroline was offered the job of medical director. Safar, too, had been left out of the city’s planning—seemingly on purpose—but he urged her to accept. She resisted. “I must be the last to abandon the sinking ship,” she wrote in a letter to Safar. “You entrusted me with Freedom House, and I will see it through to its conclusion.” Leveraging her position as the only person in Pittsburgh with direct experience running an advanced ambulance service, she told Flaherty that she would accept the job only if the Freedom House medics and dispatchers were hired alongside her. “There are 30 human beings at stake in the present power shuffle, and they count for more than any title the city or the university could bestow on me,” she wrote. She also asked that the city do its best to keep the crews together and that, on the day of the official changing of the guard, it arrange a formal ceremony to acknowledge the service Freedom House had provided Pittsburgh. “Anxious to avoid confrontation and another ambulance controversy in the press,” as Caroline later wrote, Flaherty agreed to her demands, with one exception: There would be no ceremony, no announcement, no official recognition of what Freedom House had accomplished. Moon and the other paramedics were in shock. “It was as if Freedom House never existed,” he said. All that remained was to close down Freedom House’s station. One day in the fall of 1975, shortly before the doors were locked, Caroline sat quietly in the front seat of a worn-out ambulance—not out of necessity, but out of devotion. As the sun streamed through the windshield and baked the cab, a frantic cry went out over the radio. A pedestrian had been struck by a car in Squirrel Hill, one of the city’s most affluent neighborhoods, one that Freedom House had never been allowed to serve. The mayor would only allow the police to cover it. “There’s pieces of his leg all over the street!” the officer yelled into his radio. “Send Freedom House!” Before Caroline could react, the cop came back over the airwaves to say that an ambulance had arrived on the scene, from somewhere else in the city. The dispatcher asked if she should cancel the call to Freedom House. Caroline listened in weighted silence. Finally, the air crackled as the policeman keyed up his radio once more. The medics on-site were panicking, he said. “We need someone here who knows what the hell they’re doing!” Caroline started the engine and hit the gas. As midnight approached on October 15, the crew room was silent. Moon stood near the front wall of glass, staring out at the night sky. The expressionless faces of his unexpected, acquired family, scattered across the space behind him, were reflected before him. Freedom House manager Bob Zepfel, a big man in a red polo shirt, grabbed the phone and dialed the Pittsburgh police dispatcher. Freedom House had received a private letter from city hall thanking the medics for their cooperation during “this difficult period.” Flaherty had closed his brief missive with the line, “This letter will serve to acknowledge the service that has been rendered.” Caroline wrote her own letter to the staff. “You’ve taken a dream and made it real,” she began. “For many of you, this is the end of a grand adventure, the end of a dream that was born eight years ago.… And if you take with you into the future the dedication and spirit and pride which you have shown in your work here, you will keep alive all that is meaningful and important about Freedom House.” Zepfel gripped the receiver as the medics, wearing their white jackets, looked on. “This is Mr. Zepfel, manager of Freedom House Ambulance Service,” he said when dispatch answered. “It is now 11:59 p.m. As agreed with the City of Pittsburgh, we are now going off the air.” Twenty-six Freedom House employees went to work for the city after that final night together. Twelve months later, less than half remained. “They were forced to hire Freedom House,” Moon said. “They weren’t forced to keep us.” In some cases, the city broke its promises to Caroline. In others, it made it all but impossible for the men to stay. Paramedics were separated from crew members they’d worked with for years. Some were weeded out with new pass-fail exams; those who made the cut were often shunted to positions that didn’t reflect their qualifications. Moon wasn’t allowed to treat patients without prior approval from the highest-ranking employee on the scene of an accident—almost always someone who had less experience than he did. Not even Caroline was immune: City officials quietly pushed her toward the door, and she left the job as medical director in 1976. Caroline went on to write the first textbook on EMS training. She moved to Israel in 1977 and founded that country’s national ambulance system. She flew medical relief missions to Kenya, Tanzania, Uganda, Sudan, and Ethiopia, then returned to Israel to start its first palliative-care program. In 2002, she was diagnosed with multiple myeloma. She spent her final days in her own hospice center, where she died at the age of 58. She maintained a close friendship with Safar until the end. He died the following year, at age 79, after being nominated for the Nobel Prize in Medicine three times. John Moon stayed on with Pittsburgh’s paramedic service. He officially retired in 2009—his last role was as an assistant chief—and started running a home health-care business with his daughter. He was proud of playing a small part in nudging American medicine into the future, even if it had been cut short, and even if most people didn’t know about it. “No one imagined the impact Freedom House would have. Generations of paramedics have carried on what we started. That’s our legacy,” Moon said. “We want to be included in the history, to have a voice.” Moon didn’t live in the Hill anymore. Still, on occasion he pointed his Cadillac toward the old neighborhood and bombed through the rolling streets. In the adrenaline rush were all the memories of Freedom House—of radio calls and heart shocks and EKG readings and blood and death and triumph and brotherhood. Since the service answered its first call, the world had changed so much, and not enough.