It takes about seven minutes for Portland Street Response to get downtown from its South Waterfront headquarters. But amid a sudden February 2023 snowstorm, GPS estimated it would take close to 45 minutes.
Regardless, the small crew of clinical social workers and EMTs on shift that day knew someone had to get there. A homeless Portlander was lying on the sidewalk, partially undressed and covered in snow, according to five separate 911 calls over the course of three hours. The man would ultimately die at a local hospital.
As the first responders drove their van through heavy snow, an EMT anticipated the person in distress may need help getting to a warming shelter. Others in the rig told the EMT to start reviewing hypothermia protocol for when they arrived at the scene, according to one person present in the van.
“Because if we show up and that person’s still there, that’s a medical emergency,” said a former Portland Street Response employee who spoke to Street Roots on condition of anonymity. “Like, I knew.”
Critics and experts say the death highlights a critical lack in the city’s emergency response system: Portland hasn’t kept up with forward-looking practices — like triage call centers embedded in its emergency dispatch headquarters — as other cities with alternative first responder programs like Portland Street Response have. Some local leaders say that’s a best practice that lightens the burden on dispatchers and improves outcomes for people in need of care.
Also at issue is fluctuating policy around which Portland Street Response staff members can defer a call to emergency medical services if they believe the situation is a medical crisis. Despite EMTs being on Portland Street Response crews, the non-police crisis response agency isn’t staffed with paramedics or equipped with emergency medical gear like an ambulance.
Before their arrival, responders told their managers the man needed medical attention rather than Portland’s behavioral health unit Portland Street Response, because he was likely enduring hypothermia symptoms.
“We never should have been there,” the former employee said. “Of course, you’re going to feel inadequate. We didn’t have the supplies. We didn’t have the know-how.”
As a young program, Portland Street Response, or PSR, continues building policies and procedures to become a fully integrated piece of the local public safety system, something Mayor Keith Wilson and city councilors have prioritized in recent months.
Still, how the city’s interconnected emergency systems interact — and who decides the appropriate responder for each type of call — can ultimately impact those in need of care.
Portland’s 911 system does not have an embedded triage nurse to assist with managing emergency resources — an approach that shows significant results in cities that have implemented those programs in recent years — like Austin, Texas, Durham, North Carolina, and Phoenix, Arizona.
Instead, Bureau of Emergency Communications, or BOEC, triages calls based on policy and protocol, according to its director, Bob Cozzie.
Experts say there is an opportunity to address a feature that has been missing from Portland’s response system. Embedding a call center within the BOEC call center, staffed with specialized triage nurses and mental health staff, can ensure the right person is going to each call.
Andre Miller, City Councilor Angelita Morillo’s chief of staff, also worked in former-City Commissioner Jo Ann Hardesty’s office when the PSR program was first developed. He said embedded nurse triage programs can help alleviate pressures on call centers and responders in the field.
“The mental health specialists or the triage nurses are able to identify the actual problem, because that’s their specialty being within those specific fields,” Miller said. “So far, Portland is not currently having triage nurses or mental health specialists that can take those calls.”
Miller said the approach can also address other aspects community members remain concerned about, like 911 hold times and emergency response times.
“It would help the dispatchers and call takers be able to get off of the phone, and then put that over to a triage specialist who can … have longer conversations with those individuals,” Miller said.
Obstacles
Feb. 22, 2023 was a cold, chaotic day in Portland. When the Portland Bureau of Transportation issued a travel advisory at 5:15 p.m., two inches of snow had fallen across the city, with a high chance two more inches could fall overnight. Multnomah County’s emergency warming shelters weren’t scheduled to open until 8 p.m.
Conditions quickly worsened. By the end of the day, Portland was buried beneath nearly 11 inches of snow — the second-highest total recorded in Portland.
Emergency systems were overwhelmed. PSR managed 43 calls that day — 60% higher than its average day that month — nearly half between 4 p.m. and 9 p.m., according to BOEC spokesperson Jaymee Cuti.
Complicating matters, BOEC was at its lowest recent staffing level with 40 vacancies. Today, Cuti said, BOEC has just 10 vacancies with some 40 trainees in the pipeline.
The onus was on responders to triage calls. But with few resources, vague information and compounding snow and traffic obstacles that night, the call queue seemed to only get longer, according to the former employee. The program operates with, at most, three units at a time to cover the city of Portland.
The first of five calls to 911 came at 5:39 p.m., reporting a homeless man covered in snow with his arms and head exposed at Southwest 3rd Avenue and Pine Street — four blocks from Portland Fire and Rescue Station 1, according to call recordings.
Street Roots also obtained call notes from dispatch. They were brief and written in all capitalized letters — standard for dispatch call notes.
“HOMELESS MALE COMPLETELY EXPOSED TO THE SNOW, COVERED HIM UP WITH A BLANKET..,” notes from the first call said.
At the time, the agency exclusively responded to less severe, non-life-threatening mental health crises. The city expanded PSR’s responsibilities to include some medical assistance in 2024.
Criteria for a PSR response at that time included when a person was “possibly experiencing a mental health crisis,” was “intoxicated and/or drug affected,” was “either outside, or inside of a publicly accessible space like a business, store, public lobby, etc.,” or was “outside and yelling.”
It could also respond if a person needed a referral for services but did not have access to a phone line, or upon request of partner agencies.
By 6:20 p.m., a second person had called: “ANOTHER W/SAME.”
A third caller at 7:38 p.m. was deeply concerned about the man.
The dispatcher told the caller someone would be there to help as soon as possible.
“OK, I’m just so worried he’s not going to make it,” the caller said, according to the recordings.
Portlanders frequently call on PSR when they see people with mental health needs, while other calls may come in as “down and unchecked,” meaning someone called 911 to request a welfare check on a person they were concerned about. That may mean a person is having a medical event, sometimes an overdose, or simply sleeping. Whatever it is, PSR responders regularly zig and zag across the city to calls marked that way.
When multiple calls in the queue are marked as “down and unchecked,” responders have few options but to respond to the nearest call in that category.
On that snowy February night, the call notes made no mention of the phrase.
“NEW CALLER SAYS SOME1 PUT A YEL PIECE OF PLASTIC OVER THIS MALE…,” the call notes said.
Call notes and recordings show dispatchers provided little new information after subsequent calls. As multiple people called concerning the same person, dispatchers asked for few further updates on the man’s condition, instead allaying callers’ fears by saying PSR was on its way, according to the recordings.
Embedded triage
It was 32 degrees outside, and temperatures were dropping. The man lay helpless on the sidewalk, a long drive from PSR headquarters — but just four blocks from a downtown fire station. Despite urging managers for PSR and Portland Fire & Rescue’s mobile health team, CHAT, to send a medical team instead, according to the former employee, PSR remained tasked with the call.
A fourth call to 911 came at 8:13 p.m., lasting 40 seconds. The caller said the man was moaning, laying on the ground with no shoes on. The dispatcher told the caller PSR had it on their list to check on him.
While PSR is responsible for determining the order of response for calls in its queue, it can request another agency respond instead of, or alongside it. But for a fledgling program facing political hurdles from the city’s top brass, the operational realities on the ground changed sporadically, according to the former employee.
Cuti said any responder could send a call back to request an emergency response partner. But at that time, the former employee said, PSR staff needed supervisor approval to request a different response — a policy that changed intermittently.
“If I could have just sent it back, I would have just sent it back,” the former employee told Street Roots. “At that point in time at PSR, that was not protocol.”
Asked if the city has worked to ensure the policy is consistent, PSR spokesperson Dan Douthit said it has provided additional training and support for PSR supervisors and staff.
“PSR, BOEC and other response partners have worked hard to ensure lines of communication are open to solve complex situations in real-time,” Douthit said.
Before the fifth caller could say what they were calling about, the dispatcher asked if they were calling about “the person down on the sidewalk.” The caller said the man had “mental issues, so he’s not getting out of the cold.” Again, the dispatcher assured the caller PSR was on their way.
Current policy is similar to that of 2023: staff are to consult with a supervisor if they question whether a call was appropriately triaged for PSR, according to Douthit. The supervisor then decides whether PSR should respond, or consults with BOEC to determine the appropriate response.
A May 2024 randomized study of Washington, D.C.’s “Right Care, Right Now” nurse triage program found that the proportion of calls that required ambulance dispatch dropped from 97% to 56%, and those resulting in transportation by ambulance dropped from 73% to 45%. That takes significant pressure off emergency responders who would otherwise be traversing the city for calls that may not require them.
But Portland has not implemented a similar program, despite city officials’ familiarity with the benefits of such implementation. Cozzie was part of the Harvard Government Performance Lab’s 2023-2024 Alternative 911 Emergency Response Implementation Cohort. Among other city officials, the group included Lisa Freeman, who is both the former Community and Safety Division performance and innovation manager and current chief of staff for City Councilor Sameer Kanal. The group worked on site at Harvard in collaboration with other cities to better understand best practices within 911 call centers and crisis response programs.
Instead, fire liaisons work directly with staff to help with resource allocation.
For behavioral health calls, Multnomah County Behavioral Health embeds a caseworker at BOEC who works with clients via dispatch — a program similar to what could be used for medical emergencies, but for behavioral health. In other words, if a person calls 911 for a mental health emergency, they can be quickly routed to a behavioral health specialist without a responder being dispatched to their home, unless needed.
Cozzie said he anticipates BOEC will soon be accredited through the International Academies of Emergency Dispatch, meaning the city could one day leverage the embedded nurse triage program for medical services that the organization offers. Accreditation isn’t a requirement for implementation, but the training could be useful, according to Cozzie.
“BOEC, along with our public safety partners, would need to review programs to determine which components would work within the current system,” Cozzie said. “Under the right framework, embedding different perspectives to assist in call triage can benefit overall response.”
High risk
More than three hours passed between the initial 911 call and first responders’ arrival. By then, a small crowd had gathered, pointing to a nearly naked man covered with a frozen blanket.
It is not uncommon for people experiencing hypothermia to remove clothing, a phenomenon clinically known as “paradoxical undressing” in which the person hallucinates a sensation of heat and attempts to cool themselves down.
Low body temperature affects the brain, making the sufferer unable to think clearly or move well, according to the Oregon Health Authority.
Those with the highest risk of hypothermia are the elderly, babies, “people who drink alcohol or use illicit drugs,” and those “who remain outdoors for long periods — the homeless, hikers, hunters, etc.”
Call logs show PSR arrived at the scene at 8:49 p.m. PSR responders took his vital signs, which showed low oxygen levels, and immediately called dispatch to request a medic. He was barely breathing but his eyes were open and he was moaning, according to the former employee.
“His face was frozen,” the former employee said.
“PSR6 NEEDS MEDIC CODE3 FOR SICK PT NOT ALERT AND POSS HYPOTHERMIC,” the call notes said at 8:53 p.m.
The man was transported to Legacy Good Samaritan Hospital, where he later died.
“We at BOEC are very sad that this community member died,” Cuti said. “We take the welfare of everyone in our community seriously and recognize the tragedy of this loss.”
TIPS FOR EXTREME WEATHER
Extreme weather events are more common — not just snowstorms, but all year round. Emergency room visits have remained higher after the 2021 heat dome than they were prior to the record-breaking event, highlighting the importance of preparing for extreme weather in the face of climate change.
Multnomah County is sharing seasonal heat hazards in preparation for hot weather this summer.
Last year, four people died in the county due to heat, and two due to drowning.
Heat-related illnesses and injuries are not solely related to the weather, according to the county. Three main factors, in combination, contribute to one’s ability to avoid harm: adaptive capacity, exposure and sensitivity.
Adaptive capacity
The access someone has to resources and conditions within their community is an important factor in determining how vulnerable they may be to extreme weather. Not everyone has equal access to resources.
“Policy and design choices have often not focused on the needs of people of color, people living with low-incomes, and people living with disabilities,” the county said in a summer heat hazard document. “This can make it harder for these groups to protect themselves today.”
Exposure
How long, how often and how many heat hazards a person is exposed to also contributes to their risk. Housing conditions, status, travel needs and access to swimming water play a role in one’s resilience during high heat.
Sensitivity
Each individual may respond differently to environmental factors based on their age, their own sensitivity, including pre-existing conditions, and their use of medication and other substances.
Multnomah County said people over the age of 50 accounted for 88% of all heat-related deaths between 2021 and 2024. Most people underestimate their own vulnerability to extreme weather.
With extreme heat comes unhealthy air quality. On the air quality index, green means good air quality and yellow means moderate air quality. Within these two categories, it is generally okay to be outside. People with respiratory sensitivity should stay indoors when the AQI reaches orange (unhealthy for sensitive groups), red (unhealthy), purple (very unhealthy), or maroon (hazardous). Via press releases, social media and on its website, Multnomah County will issue advisories when the AQI is red or higher.
Multnomah County said the risk of drowning is heightened in the summer months, as people tend to spend more time in the water. Wearing a life jacket is highly recommended when swimming to prevent the risk of drowning. While not all incidents are fatal, being submerged under water for a long period can have significant health outcomes.
“These include discomfort breathing or swallowing, mental distress, long-term disability and brain injury,” according to the county.
Recommended locations to cool off when the weather is hot:
Public libraries
Movie theaters
Arcades
Swimming pools
Malls, grocery stores, bookstores
A friend’s house with air conditioning
Shade at a local park
Multnomah County says it will consider activating cooling centers or shelters in areas of the county forecasted to pose a “major risk,” meaning a category three out of four on the National Weather Service HeatRisk Index, which accounts for temperature and humidity to create a risk scale for illness and injury. A “major risk” heat level affects anyone without effective cooling and/or adequate hydration, according to the National Weather Service.
The county will activate cooling centers when forecasts pose “extreme risk,” or a four out of four on the HeatRisk Index. That means a long-duration extreme heat with little to no overnight relief. This heat level affects anyone without effective cooling and/or adequate hydration.
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This article appears in May 21, 2025.