Feel that something must be done. So one route of placing them on hold wouldi be special calling of Police Officers. Police officers are quick to place someone on hold that are a harm to themselves. But disabled is another, and Police Officers in my opinion are not the best agency to do that. Thats one reason we now have psychiatrists a psychiatrist and a psychiatric Nurse Practitioner on the ride along with us. They have been extremely helpful when we approach that individual and recognize that this person does not have the capacity to care for themselves. So address your question specifically, we have a very Good Relationship with the police, but at times, it seems their mission is different than ours, and we are able to help the people that need help with the Behavioral Health team of street medicine. Commissioner veronese so i thank you for that explanation. And i think whats important for this commission to hear is that the Police Officers job is part of the criminal justice job. Theyre part of the criminal justice program. And i would assume its my opinion that theres many people in this room that would agree, that if somebody is unable to care for themselves or they have some mental instability, and thats typically what it is, that thats not Law Enforcements job. We dont want them in the justice system, we want them in the health care system. Its a trick question. That was a softball. And then, the other side to it is the Police Officers dont have that medical experience and especially captain you know, captain e. M. S. Medical Level Experience to know or to be able to make a call that this person has some sort of disability or ailment that is threatening to their lives. They just they dont have the training for that, correct . I would say that youre correct. Commissioner veronese okay. And then, the same is also probably true for psychiatric people that are with you. You mentioned you had some psychiatric people that are on your team that are with the department of health. They dont have the training or the certifications to actually make a medicalrelated call, correct . Id say yeah, i would say, commissioner veronese, you bring up the exact challenge with a lot of our clients is the interaction of all of these things and trying to sort out what is possibly behavioral versus psychiatric versus medical. And sometimes, i would say this is exactly why we collaborate on a multidisciplinary level because it takes all parties to be involved. You know, to our to the credit of our kind of Behavioral Health and street medicine collaborators and partners, they do have a lot of expertise in this area. But with that being said, our clients are people that are really, really challenging. So its not often, but there are times when everybody theres not consensus. We dont all agree with what the underlying cause is, but i readily agree with your point that it can be very difficult to tell sometimes. Commissioner veronese i think the point im making is that every Single Person thats a part of that team, whether its an e. M. S. 6 captain or a psychological team person or a hot team person, every one of those people bring a specialty skill to the table, otherwise, theyd be useless to that. And its obvious that e. M. S. 6 brings that medical part to it because thats what theyre there for. So i guess my question and dr. Yates, you can answer this question, or chief, you can answer it. But would it be helpful for your job for e. M. S. 6 captains to have the ability to 5150 people . Is that a tool that you would like to have in your tool box so that you could do it . Because i was a Police Officer back in my younger years, and i can tell you one thing, and you guys probably have that same exact experience. Is that when a Police Officer shows up to a mental case, and the Fire Department shows up to a mental case, its two entirely different reactions. And i saw it when i rode with captain simon that day. I think we were over behind the federal building, and we were there to interact with an individual that was there, and the Police Department showed up. And the moment the Police Department showed up, that individuals attitude turned hostile. And that attitude is not helpful for the our ability to give the type of care and the type of resources that we need, right . That happens out there. Am i wrong about that . No, it does indeed happen out there. Yeah. And that is the challenge. And i want to get back to your central question about the nature of involuntary holds and where that sits in terms of the tool box that we see in e. M. S. 6. I would say that taking away a persons ability to decide for themselves for their care, where they want to be and that is not something to be undertaken lightly. Its an immense challenge ethically, legally, even medically. And you mentioned things about the relationship or the clients and patients perception of whos trying to help them. That relationship that we establish is of paramount concern. Now to get back to your question, its something that we undertake as a last resort, and we we rely on the collaboration and ability to involuntarily detain folks when its done in conjunction with Law EnforcementBehavioral Health, and there can be agreement about that. One thing i do want to stress is a 5150, 72hour involuntary detention is a means, but too often, we dont think what has to happen after that. 72 hours is not a lot of time to change a life for someone. Unless we have the back end figured out, i think we should not be extremely, you know, too eager to involuntarily detain people unless we understand what the overall game plan is. So to answer your question, it is something that we do rely on in very in situations of last resort, and we do it in conjunction with Behavioral Health partners. Thats the only way we can make these things stick and make them work. Going back to someone again and again and again as a very disturbing cycle, and i think that thats something you would agree as a Law Enforcement officer. Commissioner veronese yes. And i think i hear you guys agreeing that this would be a useful pool because adding the Law Enforcement tool to that as a last resort but you guys are more qualified to assess whether somebody is capable of ending their own lives than any Law Enforcement is able to do it. So i guess my question is, is it a tool currently, legislatively, you guys cannot do it. But if it was a tool at last resort that you would like to have in your tool box in those cases in that you are more qualified than other people around you to use . Let me try to answer that. So i think that i think that if we could place a hold, we would do so effectively and judiciously. There are times when more people are not able, and in those situations, if we had the ability to do it ourselves, it would be helpful. But there are other considerations that are tempering my enthusiasm on being able to effect a hold. As d we would want a more collaborative Decision Making approach before putting someone on hold. So for example, Law Enforcement felt this way, we felt this way, a psychiatrist or social worker felt this way, and then, that hold has more weight. If we, you know, place the hold, then i would not want some advocate for peoples rights to suddenly think were the bad guy. Were taking peoples rights away. That would be really challenging for us. And the other thing would be, theres a benefit for something a psychiatrist placing a hold, and that is a psychiatrist has that relationship with the other physicians at psychiatric emergency or at the other hospitals. They could follow that patient through and lend their professional opinion in a way we could not. So that would be really the having a clinical a Mental Health professional right the whole i think is the best way to do it. Commissioner veronese so when a 72hour hold happens and i know this because ive done it as a Police Officer. That person is brought to a hospital by law. That person is required to be brought to an institution issued by the state. Many institutions at San Francisco do because theyre at that level. And then, immediately upon entrance, they are seen by a doctor who does an analysis themselves as to whether or not to waive off the hold to let that person go or to hold that person longer. So maybe you dont have the experience with it, doing the holds themselves, but i think a little bit of training behind what it is that goes behind that would be really helpful. But i guess what youre saying. My Biggest Issue when i brought this up is we have got such a great reputation out in the field, and this is why i didnt want to push it. Do we want to tar initial thni representation, when somebodys life is in danger that we want to take them in custody . I feel like the cops have the authority to do that, but this is not a criminal justice issue. Those people should not be in that system. Because the moment a Police Officer writes a 5150, theres a Police Report behind that, and then, theyre a part of that system, and they shouldnt be a part of that system if its a mental or medical issue. So i go back and forth on this thing. And i really would like you guys to have that ability, a tool in your tool box if you need it when other people arent around. And just for education of the other commissioners, i spent about four months on this issue with the City Attorney going over the 5150 law. And i actually wrote a resolution to come to this commission. Because the reality is that we can as a commission and then it would then go to the board of supervisors, designate e. M. S. Captains theres a specific term in the 5150 code. Its like an Emergency Task force, and it is. Its a task force to deal with a particular emergency. We could determine them to be under 5150, and it would give us the ability as the hospital sanctioned it. So there is a resolution thats within written to do this been written to do this. But i would push it if it came from you guys and the chief first and i ran it by the former union boss, who supported it. But my point is, if its a tool that you really want, talk to the chief about it. This commission has the ability to give that tool to you that would then go to the board of supervisors for approval. So ill move on from that and let the others comment on. Its a hot topic to really kind of its a hot potato topic, but it pains me to walk over people on the streets of San Francisco where they have a mental issue, and could possibly harm each other. We saw that event in north beach, and that lady had a Mental Health crisis. We see it occasionally, people that could have been helped by us, and i dont want to see us not helping people because we dont have the right tools. Quick question, and another potentially sensitive question for you is when we create a program like this, and we see that program is effective you guys 19 reduction is amazing. Those numbers are really, really, really good, and the department is throwing numbers at you because youre an effective unit. At some point, i dont want to create an institution around a problem, right . We do a really good job of that here in San Francisco is creating institutions around problems. And then, it gets really hard to, once you solve that problem or once you come up with ideas to solve that problem or really good, to do away with that unit because its no longer needed. So i wouldnt want to see that happen because i like the Fire Department getting money, but at a certain point, youre going to do your jobs so well that were not going to have frequent callers. I know its a pipe dream, but id like to see this Program Transition into Something Else when we become so effective, and the other departments have stepped up, where we dont have this need anymore. So id like to maybe have the department to come up with some sort of plan, a tenyear plan of some kind of how we transition this unit into Something Else once weve solved the problem because solving the problem is the goal, not creating another institution that the taxpayers are going to have to pay for around, you know, a problem that were not going to solve because were getting money every year. Ive seen city departments do it. I worked for welfare fraud back in the when i was in my 20s. I was a senior investigator for the welfare fraud division, and i saw how that department didnt want us taking people off of welfare because it was less money for their department. I dont want to see that. I want to see us doing our job so far that its not needed anymore, but transition this department into something more effective. So id like you to have a pipe dream with Something Like a tenyear plan so we can transition into something because weve solved that problem or working towards solve that problem. My last question is commissioner hardeman had mentioned the touchy issue of at a certain point how many calls becomes a crime . And i know theres questions you asked about that. Whats the mental capacity of this person . Is he doing it intentionally . But do you ever come across people that are just calling 911 i know you told me about one guy that called 911 because he was having troubles with his remote. It turned out he was just lonely, but when you call 911, were going to respond. How often do you see those types of calls in this unit and what do you do about it . Well, first of all, ive been in the Fire Department for 24 years, and i do know that there are times when people maliciously activate emergency services, and it sure is irritating. But in the last nearly four years, our people that weve been working with, that has not been the case. Its entirely rooted in dysfunction, disregulation, untreated mental illness, Substance Use disorder, one subset, because not all of our people are homeless. Theres about 28 of our people annually that have residences that live in the sunset, the richmond. Maybe theyre end of life, and we help them, too. Its a totally different set of tools. We assess the situation, we call their doctors, we all i. H. S. , we call d. H. S. Fortunately for us, i dont think of a Single Person whos, like, been on our list thats been [inaudible] but it hasnt been if it has been malicious, their primary cause is mental illness, Substance Use disorder. Commissioner veronese and thats part of the job. I guess it. Thank you so much, all three of you, for answering the questions. They were sensitive questions, tough questions, but were here to ask those questions. If theres anything that we can add to your tool box to make your jobs more efficient, better. Thank you. President nakajo thank you very much, commissioner veronese. Before i get the other commissioners in, doctor, did you have anything . Yes. Thank you, commissioner veronese. One of the things that weve learned is its about the multiagency coordination. I do not think that at this time that thats an overriding need for us to independently do something. I would emphasize and assure you that it is something that we do undertake. It is something that we undertake with our partners in collaboration because of all the reasons that are sort of specified. Well definitely take it up if we have issues that need to be addressed. Thank you. President nakajo thank you very much. We have other commissioners. Commissioner cleaveland . Commissioner cleaveland yes. Id like to pick up on commissioner veroneses comments on the mentally ill. What percentage of your clients are mentally ill people versus addicted people and whatnot . I was looking at our internal data, and frankly, we dont have any internal data that measures what percentage of of the individuals that are homeless. Id say its very high. And what i would we dont have an exact number. I would sort of tell you that the the the rate among our highest users is very high, so people tend to have the combination of Substance Use disorders, mental illness, and medical challenges, and those three things together have caused people to require a lot of needs in the safety net. I do want to also just emphasize that that is not to say that the opposite is true, that people who do have Behavioral Health issues are automatically frequent users. So sometimes we get confused about that distinction. But to be clear again, many, many, the majority of clients that were seeing on a highest user basis do have competent psychiatric and incompetent psychiatric and psychological challenges. But the opposite is true. All people that have Behavioral Health challenges are not frequent users of 911. But we continue to see those people that do. Commissioner cleaveland so the people that you do continue to request a 5150 through Law Enforcement, what percentage of those what percentage of the people that you deal with are actually detained under 5150. Thats a good question. We dont also have that we also dont have that. Yeah. I think one of the challenges as i kind of alluded to before, a shortterm involuntary hold is exactly what it is. Its a shortterm involuntary hold, and the longterm challenges persist after that. If you put someone on a shortterm psychiatrist hold and they demonstrate that they have Decision Making abilities, we have no right, nor should we, of detaining them against their will. And if that happens many times again and again and again, then, we have to look at some possible solutions. And one of the cases that we looked at illustrates that process. It has to do with conservatorship, it has to do with things like longterm stablization. We try to avoid looking at those situations, but it does happen sometimes. Commissioner cleaveland if theyre sent to a hospital sometimes, are they under lock and key . No. They could be taken to any of our emergency rooms, where they could be handled differently. Sometimes the emergency room doctor will assess the patient and release the patient, drop the hold. They feel that whatever conditions existed a few hours ago no longer exist. Commissioner cleaveland they have that right . Yeah, they have that right to do that. Other psychiatrists wait until they can assess the patient. Dr. Yates, you can probably better speak to this. Yeah. We have one facility with psychiatric services, s. F. General. So people that have sustained involuntary detention and require longer term care ultimately do need to be transferred to that location if thats what your question was. Commissioner cleaveland if theyre in for 72 hours, do they get over their alcoholism in 72 hours . I dont know. Does it take more than 72 hours to detox an alcoholic . Absolutely. And there in is the challenge, that holding a person that may not want to go for evaluation at that moment is a beginning, but then, we have to go through the mechanisms to determine whether they can continue to decide if they wish to have treatment or not. And unfortunately as all of us know, addiction is a really challenging issue, and not the least of it is peoples willingness to engage in treatment. And being able to voluntary detain a person is a pretty blunt instrument. But to get to your point, very infrequently are we able to address the longterm problems in 72 hours. Its a very long path after that. Commissioner cleaveland so the situations that you call for involuntary intention or 5150 is a very small percent. Yeah. Commissioner cleaveland so commissioner veroneses idea of giving you to do that, to do a 5150, would you see that percentage increasing . Thats a very good question. To be right to be completely honest, i dont know the answer to that. And i think that right now, it is a thankfully a rart that were doi a rarity that were doing that, that we have a person in the system that needs to be involuntarily detained, and we need to have the resources to be able to do that. But what would be the effect of us having that ability, i do worry about that. And thats a very real real issue. And i also think that Law Enforcement, we rely on them a lot in these situations, particularly if a person we are deciding needs to be detained disagrees with us, and does not wish to be detained, does not want to go to a voluntato an iy treatment situation. Commissioner cleaveland well, i fully support the progr program. As commissioner veronese mentioned, i think you need all the tools in your tool box. I would support giving you the 5150 ability because i know you would use it judiciously. In terms of you being in service, youre not a 24hour service. Youre 18 hours, is that correct . We very soon will be 6 00 a. M. To 2 00 a. M. Seven days a week. Unfortunately, captain sloane has a bad ankle and is on modified duty, otherwise, we would be there. So half the week, we work 6 00 a. M. To 2 00 a. M. , and the other half, we work noon to midnight. We are going to have reinforcements very soon. April will recover eventually, plus we still have three additional captains to be on boarded, which we hope to do by march of 2020. And at that time, we will be 6 00 a. M. To 2 00 a. M. , seven days a week. And at the high point of the day, well have four units on at the same time. So were going to greatly increase our our bandwidth, and we hope to demonstrate were going to increase our productivity annually. Commissioner cleaveland so youre on 6 00 a. M. To 2 00 a. M. . Yes. And weve chosen that because we looked at the number. The low point of 911 frequent utilization is between 2 00 a. M. And 6 00 a. M. And also, there are very few Resources Available between 2 00 a. M. And 6 00 a. M. , so even if we got to somebodys side during those hours, we would just be minding them, just be sitting with them. And most people dont want to emote at 3 00 a. M. , so we just dont think thats a good use of our resource. We think its better to double up during peak hours. Commissioner cleaveland so you do have the funding in place to do it all but four hours of the day in the Early Morning hours. Yes cleaveland clae. Commissioner cleaveland thats in place . Yes. Commissioner cleaveland that funding is in place. You mentioned about e. M. S. 4. Whats going on there . Ours is a cuttingedge program, and there are other efforts to reform e. M. S. Services in other areas. I think at long last, its gotten the attention of reimbursement and policy change. One of these things has to do is the federal government as an initiation pilot initiating a program in which they would allow certain places to get reimbursement from medicare, from caring for Medicare Beneficiaries in ways other than transporting them to the an acute care hospital. Let me back up and just sort of say from a Health Care Economics standpoint, from medicare, medicare reimburses for transport to an acute care hospital. That is that is it. Commissioner cleaveland thats all they cover currently, and thats about 400 a pop. Thats correct. Thats correct. So if we engage a client in their home, manage their medications, offer alternatives in a deferred appointment where they can seek medical care and not bring them to the emergency department, we are not eligible for reimbursement by medicare for services rendered. I think the federal government is realizing that thats a cost savings, and theyre trying to better implement that with things just as the e. T. 3 program. Now, we met the deadline, kicked in an application, but we probably wont know until sometime in the spring if theyve chosen to extend us into the program. Commissioner cleaveland but if they accept our program, it could be a yes. Commissioner cleaveland an additional source of revenue to the program. Yes. The only thing i would temper that a little bit is to recognize that is specifically for Medicare Beneficiaries. That doesnt necessarily reflect other payors in our system, and depending on which subgroup you look at, Medicare Beneficiaries may not be a large portion of the individuals were caring for. I think the Reimbursement Policies change throughout, but at the same time, i wouldnt expect there to be a massive influx of funding from that particular program. Commissioner cleaveland thank you. Chief pang, you mentioned the meth Sobering Center idea, but i assume its simply an idea at this point, and youre part of the task force, which i think is very important. What does that mean . What is a meth Sobering Center . Well, methamphetamine users stand out because they are very frequently behaviorally disruptive. So, you know, you take them to an emergency room, and they blow the place up. Theyre shouting and screaming, and oftentimes, their medical needs are met. Theyre not in acute medical stress, but they are detoxing from the drug, and what do you do with that person . And we have a Sobering Center for people that use alcohol. It works very well, but we cannot just send someone whos high on meth there because they will be disruptive. They will be bouncing off the walls. So the idea is to have an appropriate place thats safe, that has clinicians there, to make sure that they stay safe, that they dont have any unmet medical needs where they can safely detox. And also, while theyre there, they can be referred to detox treatment resources. Commissioner cleaveland have you determined a site for this . Oh, no, thats far above my level of involvement. I went to four meetings and collaborated and gave my input about the challenges that we face. Now that its been brought up to the health department, the mayor, supervisors, and its now for them to decide what comes next. Commissioner cleaveland okay. Thank you very much. Well, i think i speak for the commission when we say we all support what youre doing out there. We know that its a tough job every day, and you have to put your heart and soul into this program. Its a reality of our society these days, and were trying to meet the needs the best we can, so thank you for all that you do. Thank you. Thank you. President nakajo thank you mr. Cleaveland. I see Vice President covingtons name on the roster. Vice president covington. Commissioner covington thank you, mr. President. Lets see, captain sloane. I just have a few general questions. So captain sloane, do the members of your team have excuse me a list of questions that you pose to people that you helped in the field . We do whats called a biopsycho social assessment . So we assess the social determinants, medical determinants, any psychological factors that might be driving the 911 calls, and we try to identify the one factor and address it, while its an unmet whether its an unmet medical need, shelter, access to primary care. Commissioner covington do you have that list with you . I dont. Commissioner covington thank you give us a few examples . This is my field level. This is what i do. Hi i dont use captain. Hi. Im april. I see youve been on the ambulance ten times this month. Im with the Fire Department, and id like to see whats going on. Can you tell us why you need to go to the hospital ten times a month . Can you tell us whats going on . They might not tell us or they might say theyre having an issue with their alcohol, and i will direct them over to the Sobering Center so they can leave the e. D. And go to another place and i can visit them at sobering and talk to them and see if theyre interested in going over to detox. If theyre not interested in detox, i tell them ill get them to sobering every night, and id prefer that they go to sobering every night instead of the hospital, and maybe they know where sobering is, and they dont have to go to the hospital. If its an ongoing medical issue, then well get them over to clinic and assess them, do their future appointments. A lot of times, we do end up manage their medications, or we might pick them up and check them, hey, did you take that today . Commissioner covington so there is a lot of follow up. There is a ton of follow up. Just because weve gotten someone somewhere slightly stable, then it becomes more intensive because we need to figure out what it is they need to continue being stable. Commissioner covington and are any questions asked regarding where they lived last . Mmhmm. How long have you been homeless . You know, when were you last housed . Was it a safe environment . We probably deal with a fair amount of people that i would consider marginally housed. Maybe they get their check and they spend a few days in an s. R. O. , but then, theyre back out on the street. Commissioner covington do you have any idea of the percentage of people who are homeless in San Francisco who were previously housed longterm in San Francisco or are people coming from other places . I dont have the statistics on that. I do know that evictions without Supportive Housing, and by Supportive Housing, i mean when a person is placed in housing, theyre placed with a hotel or s. R. O. That offers social work, onsite medical, that sort of thing, their chances sustaining it are still pretty low. I dont know how many people we have coming from out of county or state to here. Most of our clients a lot of our clients are longterm homeless people. Commissioner covington i see well, thank you, captain sloane. So for you, former captain now section chief pang, can you please tell us a little bit about the Conservatorship Task force . Can you tell us, if you know, when will the task force be presenting its findings and its recommendations . Well, weve only met once so far, and the work group the housing conservatorship work group, is that what youre referring to . Commissioner covington yes. Weve only met once, and i think the next steps are going to be identifying people that are eligible for this conservatorship. Now commissioner covington people who are eligible to be under conservatorship or people who are eligible to be trained as conservators. Oh, no. Eligible to be conserved under this new conservatorship law. So this new conservatorship law was signed by Governor Brown in late 2017. It is a Pilot Program for three cities in the state San Francisco, san diego, and los angeles. Commissioner covington so the three largest cities. Right. And it was made it was crafted for a need that senator scott wiener identified, also with former director barbara garcia, that there were some individuals who cannot take care of themselves and are dying on the street who dont want to be helped. We might meet them over and over again, and they will not take us up on our offers for housing. They wont do it. So what do we do with those people . And as it turns out, there is a small group that do not fit under current conservatorship laws, l. P. S. Conservatorship. There is a new tool, and there are a lot of protections to prevent peoples rights from being abused. We dont have anybody yet that has been activated under this law. What has to happen is they have to have eight or more 5150s in a rolling 12month period, and they have to have been referred to a. O. T. , assisted outpatient treatments, if they are eligible for a. O. T. , and they have to have been demonstrated not to have succeeded there. And they have to be given advance notice that conservatorship is a possibility. They have to appear before a judge. They can plead their case with an attorney before the judge, ultimately, it would be up to the judge. And there is a onemonth preliminary period for them to stablize. If they dont stablize for one month, then, they could be housed for up to six months, and during that time, they would detox and receive treatment, and they are guaranteed permanent Supportive Housing after their conservatorship. Its something that two years ago, there was a lot of push back from advocacy groups, but the bill was amended and amend amended again, and now, i think theres still some reservations from Civil Rights Advocacy groups, but i think that its its going to go forward, and i think its going to show some benefit. Commissioner covington okay. Thank you. I also think it will show some benefit. You know, there are numerous models of conservatorship, you know, for the elderly who dont have family close by and people want to make sure that someone is looking out for their interests and making medical care available to them on an asneeded basis and all of that. So, you know and scheduling and home care and that sort of thing. So there are a lot of different kinds of conservatorships, and i think that thats just another example of the kinds of things that can be done to help people that cannot help themselves. Its a very, very complex thing. I dont think any of us, 20 years ago, would have imagined we would be where we are now with so many of our fellow americans sleeping on the streets and there being this toxic soup of of mind changing drugs. Its not one kind of drug. I notice that there are an increasing number of heroin addicts in San Francisco now. I hadnt seen a heroin addict in the longest time, but people are nodding off in corners, and oh, my goodness. You mean that heroin is making a comeback . But it seems to be. And youve got meth, and it goes on and on. And youve got alcoholism, and each of these dependencies has a different approach to getting people to understand what youre trying to say to them. So i really admire the work that the team is doing, and thank you so much for your willingness to do this. And it really heartened me to hear you say, section chief pang, that our people have these kinds of issues, not those people, but our people because these are our people. You know, were all human beings, and we want the best for our fellow human beings, and it is not we are not a Successful Society. We may be the richest and the most powerful, but we are not a Successful Society when you walk out your door and you see people sleeping on the street in these numbers. So the medical support and the 5150 hold, i just transitioning to Something Else, i think that unless you lobby the commission to have you have that ability, that i think its best left to other people. I think the psychiatrists, you know, are powerful, powerful, and brilliant people who are not just medical doctors, but they specialize in this i mean, for years and years and years before you get a chance to call yourself a psychiatrist. So they can prescribe the meds, you know . Our our firefighters, our captains, our chief of the department cant write a prescription for someone, and so we need to have that separation and not slow down the process, you know . This person needs to see a psychiatrist and get them in there, and let the psychiatrist make the determination on the 5150 hold. Thats what i could do you concur . I do. I appreciate your comments, commissioner. And i do also just want to say, i absolutely i would say none of our discussion about whether we have unmet needs is in any way supposed to be diminishing the ability for health care for pafrl health professionahealth Behavioral Health professionals. I think psychiatrist provide an assessment. They provide their Mental Health perspective, and thats really important down the road for sustaining conservatorship or longterm care down the road, so i agree with that. Thank you. Commissioner covington thank you. And thats what they do all day. They focus on that. Whats going on with your brain, whats going on with your body, and how do we get the two working in concert so you feel as if you are a whole human being. Lets see. Im mindful of the time, so i will hold any other questions that i have because president might have one or two. President nakajo thank you very much, Vice President covington. Thank you very much for your presentation. I do have a few comments. I also wanted to express appreciation for this very important dialogue that occurred this morning all the way from commissioner veronese to commissioner cleaveland, and i know that commissioner hardeman has been involved in this, as well. This has been very long this morning, very educational. Theres a lot of briefing, but a lot of education, and a reminder of circumstances, as well. So much education that i had to keep on drifting back to the purpose of when we started this whole e. M. S. 6 as our commissioner that talked, and we were engaged with this identification of frequent fliers, and engines and trucks were going to the streets and seeing these individuals repeatedly over and over again. Folks used to ask me, besides the engine, how come theres an ambulance there, as well. The same results occurred. You picked up the member, whoever it was, of the public im generalizing, took them to the hospital and dropped them off. The hospital had to go into their mode, and during these set of circumstances, the person was discharged, and two hours later, that engine or truck would respond, as well. I remember that because i went on a ride along, specifically asked to be on the right alongs in the targeted districts to see for myself in terms of the attitude of the Fire Department of trucks and ambulances responding to. And basically, we picked up our patients, did our jobs, dropped them off. So the e. M. S. 6 was a mechanism, dr. Yates, introduced really early that i had to understand, as well as my colleagues, what is the purpose of this, to treat the frequent fliers in specific instances and modes and then continue to do their task . And only with the if phenomenof e. M. S. 6 do we have this twohour discussion in terms of the information and detail of education that we have inherited. We serve the public, and we wouldnt have this kind of detained information and case studies if we didnt have e. M. S. 6 with these examples in terms of our effect. So to me, these case studies are very, very important. Sure, theyre very important in terms of the case studies and the numbers, but part of the department, our duty is, we save folks lives. We respond in terms of prevention, we respond in terms of fire suppression, but we know have a purpose now have a purpose, and you specifically talked in some of these examples about saving lives. So over the years, they have identified all of these multiple issues of how people care. And if anybody cares in this department, its members of e. M. S. 6 and this department that charges us to go out there. We know we need coordination between the homeless center, navigation center, and shelters. Id rather have the coordination of a team that understands what were going through so that we can do the job that were entitled to do. So with regards to the team, i see some great worth to e. M. S. 6. In some ways, were drifting in patientclient care, but in other ways, we get them off the road so that they can be part of society, as well. I know this is a very complex issue, but its an issue that i am, the commissioners are greatly appreciative in terms of the work that you do. Its amazing how dr. Yates, section chief pang, april, in terms of the team of three that has now grown and are now trying to be effective. Its a great thing, and i still see many things that have to be developed from that, as well, as we try to move down and try to be innovative in terms of caring for San Francisco. I thank you for your report this morning, dr. Yates. Thank you. Dr. Nakajo. I would say the commission has been great. The department has always been supportive of this. I would point out that although the e. M. S. 6 team spend all of our time working on this, responding, we really depend on all the members of the Department Working on calls, responding, identifying when patients are at risk, even just identification and supporting. Really this is a Department Wide effort. Although the e. M. S. 6 team may be the mechanism, it depends on the team that are responding to the people. Im grateful to the commission for this discussion today. President nakajo you folks are the boots on the streets. You are the ones that are dealing with it in terms of the streets of San Francisco and its not easy. Thank you very much. Madam secretary, can we recall chief wyrsch in terms of completing item 6 on the agenda, and could you read that item, please. Clerk yes. Report from operations, deputy chief, victor wyrsch. Report on operations, including greater alarm fires, medical services, bureau of homeland security, and fire operation. Commissioners, chief nicholson, good morning, kathy. Deputy chief of operations, victor wyrsch. This is my Operations Report for october. My greater alarm report, there was a second alarm at 1225 hours at 255 vienna, cross streets of avalon and excelsior. You can see from the velocity of the smoke and the fire, i just want you to be aware that at this time, we had companies prove that when they first responded, the garage was closed. Were getting a lot of good footage from ring, neighbors across the street. Originally, one of the tenants had the garage door open, and like the louie lembretti fire, the wires connected from the garage door opener, and it automatically closed. So when Companies First pulled up on scene, they saw the garage closed, and they go to loss of life. They went to the floor above, which they endured a lot of intense heat and a lot of smoke, but they brought a line, and along with rescue two, checked the top floor and made sure there was no victims up there. They did an aggressive attack. Because of the zero Property Line and the fire started impinging on the exposure b chief, fire chief pulled a second alarm. They were able to breach the garage door, immediately bring lines into the bottom floor and extinguish the fire, pushing it out the back. The fire building took three hose lines and ventilation to control. The bravo had two hose lines into the interior to extinguish. After the fire was out, because it was extensive damage and a stairway collapse in the partial and a partial collapse of the rear of the building, after the fire was out, we got to use two of our fire search dogs. We ended up not able to find some pets, so they were able to go in and find two of the pets, unfortunately, with negative results, but we got to use the fire k9s. Three civilians were assessed medically, one treated for partial thickness burns and smoke inhalation. We had four firefighters that were assessed. One was transported, but the firefighter was later released and returned to duty that day, so it was a very good job by all the companies. Also, you know, we responded to the kinkade fire on october 25. A strike team responded, and they positioned near highway 28 near healdsburg. The strike team was engaged throughout the night and into the next morning fighting that fire. During the next operational period, the strike team was assigned to a rural area near mark springs west road, and engaged in mopping up hot spots and tactical control among other properties. The strike team spent a total of seven days assigned to the incident, completing various assignments and returned on october 31. In addition to that strike t m team, we had engine 361, o. A. S. Engine went out with the o. A. S. Strike team with marin departments. We had a total of 36 firefighters that assisted in the kinkade fire, and at the time of employment went from seven to nine days. And as the chief had mentioned, c. D. 1 and c. D. 3 went up, and that was really good for mo morale, visiting the crews and giving them fresh supplies. I put up a picture here of the fire that was on masonic and oak. That was led by assistant chief rex hale that is here today. Although it was a first alarm, it was very impressive. We had a lot of fire blowing out the top two floors of the structure, and the fire actually started we believe it started in the front doorway. The initial fire tag team went up the front steps, extinguishing fire all the way up. Hit the top floor,