PITTSBURGH (AP) - The call came in at dinnertime: an 11-year-old girl, not breathing.
Pittsburgh paramedics with Medic 8 supposed the girl was choking on her food as they raced to the address in Beechview.
But paramedics with Medic 2 got to the home first and sent out an update over the air: The girl showed telltale signs of heroin use. This was an overdose.
What followed was unique only because of the girl's young age.
The paramedics gave the girl Narcan, a nasal spray that reverses the effects of opioid overdoses.
The paramedics gave the girl an adult dose of naloxone and revived her. The drug, often known by the trade name Narcan, blocks the effects of opioids, and can save patients from otherwise fatal overdoses, but also plunges patients into immediate physical withdrawal. The girl, like many heroin users, became combative and nonsensical when she was revived. Paramedics sedated her on the way to the hospital, and left her there in stable but critical condition.
This happens, on average, eight times a day in Pittsburgh. The call for an unconscious person, the Narcan, the anger and withdrawal is routine - so routine that it's easier for paramedics to count days without overdoses than days with them.
The city's paramedics are on the front line of the opioid epidemic, a growing wave of people abusing opioid drugs. In 2012, paramedics responded to about 900 calls for overdoses in the city; in 2016, it was 2,300. Pittsburgh EMS Chief Robert Farrow expects calls for overdoses to hit 3,000 this year.
The sheer volume takes both a practical and psychological toll on first responders. Paramedics save the same patients so many times that they know their first names, watch fathers perform CPR on sons and listen to children call out for unconscious, overdosing parents.
They see firsthand how addiction wears on family members, and witnessing that pain can be the hardest part of it all.
"It's a living suicide," Medic 2 crew chief Stacey Yaras said of addiction.
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At 10:34 a.m. on Friday, EMS District Chief Jeff Meyer received a call for a man down, unconscious and not breathing, a suspected overdose.
He flipped on his truck's red lights and sped to the home on Woodbourne Avenue in Brookline.
"This could be cardiac arrest, this could be dead or this could be a little Narcan goes a long way," District Chief Meyer said on the way, laying on the horn as he escaped Downtown traffic.
When patients overdose on opioids, their breathing slows, they fall unconscious and then stop breathing altogether. The heart continues to beat for a few minutes, but the body soon runs out of oxygen, which leads to cardiac arrest.
The first step to saving an overdosing patient is to breathe for them.
But when District Chief Meyer reached the home on Woodbourne Avenue, there was no point.
Timothy Buehl, 25, was on the floor, curled up in the fetal position, surrounded by stamp bags. He'd been dead for hours.
District Chief Meyer made the official pronouncement.
A few minutes later on the front porch, the home's owner, Thomas Alexander, watched a stream of investigators troop in and out: Pittsburgh police officers, detectives, a crime scene photographer. The Allegheny County Medical Examiner's office was called to remove the body.
"I got up there and he was cold as ice," Alexander said. "I reached down and felt his hand to do his pulse and it was freezing. I knew he was dead."
He stared off, looked down at his hands. The 25-year-old man was just visiting the home, he said.
"He's not a bad kid, he's just a bad addict," Alexander said. "He couldn't stop."
"I've had the same guy overdose three times in three days," said Jonathan Dalbey, a paramedic with Medic 2. "You go and take care of him one day, and then you take care of them the next. It's sad because eventually they're going to die."
During 2016, 613 people died from overdoses in Allegheny County, compared with 424 in 2015, according to the medical examiner. In 2012, the county saw only 290 overdose deaths.
In Pittsburgh alone, at least 74 people have died from suspected overdoses so far this year, according to police, compared with 130 in all of 2016.
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It's relatively simple for a paramedic to save someone who is overdosing. Ten years ago, a heroin overdose call was a big deal, Dalbey and his crew chief, Jeff Reim, said.
"Now, it's like a drill," Reim said. "We could do it in our sleep."
"I think my record is four back to back (overdose calls)," Dalbey said. "We know when a dealer hits an area because all the sudden you'll have like eight overdoses within an hour."
Overdoses are most often dispatched as top priority calls because they usually involve someone who is not breathing, paramedics said. That means a medic unit with an ambulance responds to the scene, as well as an EMS supervisor and rescue truck, a fire truck and multiple police units.
And when those first responders are at a heroin overdose, they can't be at a car accident, for instance, or at a home where a woman is experiencing chest pain.
That's true for any call, paramedics said, but overdoses strain the system because they happen simultaneously and frequently across the city.
"You might have four or five overdoses going on at one time, and you have med units out at each of those," Dalbey said. "It's rare that you would have multiple people having heart attacks at the same time. We have a limited number of ambulances, and as call volume goes up, response time goes up."
Right now, EMS can keep up with overdoses and other medical calls, Chief Farrow said, although that could change if overdoses continue to skyrocket in coming years.
Other first response agencies have already made changes at their departments to adjust to the flood of opioid use. Allegheny County Police added eight detectives to their narcotics unit about a year ago, nearly doubling the unit's size, Lt. Jeffrey Korczyk said.
Pittsburgh narcotics detectives now investigate overdose deaths, and most of their work these days is spurred by a death, rather than by citizen complaints, as it was in the past, Detective Calvin Kennedy said.
Police officers and firefighters carry naxolone in their vehicles.
For the time being, first responders are coping with the practical demands of the opioid crisis, officials said.
The psychological toll overdoses take on first responders themselves is perhaps more pressing, District Chief Mike Rogers said.
"Trucks we can replace," he said. "It's the wear and tear on the people."
Nine times out of 10, patients saved from an overdose with naloxone aren't happy to be saved, Dalbey said. Torn from their high and dumped into withdrawal - which feels like the flu on steroids, every cell hurts - overdose patients often lash out at paramedics, and it's hard to constantly save patients who berate you afterward, paramedics said.
"You can only get screamed at for so long before you think, 'Is this really worth it?'" Dalbey said.
And yet it always is, he and other paramedics said.
"It's not our job to judge people," Reim said. "Everybody deserves to be saved."
Information from: Pittsburgh Post-Gazette, http://www.post-gazette.com