TAMPA — Paralyzed from the waist down, Khalid Mahmud spends most of his time in a hospital bed in his living room.
For the most part, Mahmud and his wife are able to meet his daily needs. But when the 72-year-old needs to use the portable toilet at his bedside, they summon help.
They call 911.
When they do, a fire engine with a three-person crew from Hillsborough County Fire Rescue's Station 19 makes the two-mile trip to the Mahmuds' Carrollwood home. Firefighters lift Mahmud out of bed and onto the toilet, wait for him to finish his bowel movement and clean himself, and then ease him back into bed.
Between January 2014 and Thursday, this process has repeated itself 284 times, county dispatch records show. In recent months, the couple have called every day.
The Hillsborough County Sheriff's Office investigated whether this constitutes 911 abuse, but prosecutors declined to pursue charges. State and county officials are trying to find help for the couple, but the Mahmuds say they haven't found a better option.
"I know their time is very important, but I do not have another source of help right now," Khalid Mahmud said this week as he lay in bed, his wife nodding her head. "I only use them when it's extremely important."
The case highlights the lack of a service that the Mahmuds say they need and that the fire department can provide: on-call assistance for a disabled person who doesn't need round-the-clock care.
"He is not the only person in this community who is paraplegic and who needs to use the bathroom every day, and Medicare is limited in what it provides," said Jay Wolfson, a professor of medicine and public health at the University of South Florida. "We don't have the social capacity and the economic capacity to deploy hundreds of people to help people with activities for daily living."
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A retired pharmacist, Khalid Mahmud has degenerative neuromuscular disease. He has been unable to walk or stand for about two years.
His wife, Rashda Mahmud, 70, works as a medical records clerk five days a week. Each morning, she leaves her husband with the medication, food and drink he needs. At lunchtime, she drives back to the home they've shared for 30 years to check on him, then returns to work.
A nurse comes once a week to help him bathe, but Khalid Mahmud said his Medicare plan doesn't cover a home health aide, so they pay out of pocket. The couple said a 2007 car crash caused by a drunken driver left the husband seriously injured and wiped out much of their savings. They live primarily on his Social Security check and her modest salary.
Khalid Mahmud said he is physically unable to use a bed pan, and they can't afford to have someone sit in the house all day. Even if they could hire an aide for a few hours a day, the couple said that wouldn't work, either.
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"If they come in and nothing happens," he said, "I have to pay for that."
The firefighters, the couple say, are trustworthy and come when Khalid Mahmud needs them.
"They put me on the commode and five minutes later they put me back in bed and off they go," Mahmud said.
The county doesn't see it that way.
"Any nonemergency call takes first responders away from what they're intended for," said county spokeswoman Michelle VanDyke. "There are better options."
First responders are required by law to respond to each 911 call. County officials were not able to provide an estimate for how much each call to the Mahmud home costs.
According to a schedule used by the Federal Emergency Management Agency to reimburse municipalities after an emergency, a fire engine costs $93.50 an hour to operate, not including personnel costs. Staffing on engines can vary, but they typically run with a fire medic, a driver-engineer and a captain. The combined minimum hourly wage for those positions is about $65, according to a 2016 county pay plan.
If each call takes 30 minutes, including the time to do the required paperwork, the combined cost to run the engine and pay the staff for 284 calls is at least $22,500.
Fire officials eventually complained to the Sheriff's Office about "excessive calls .… that do not fit the criteria of a true emergency," Deputy Ricky Siebert wrote in an April 29 investigative report.
By the time Siebert visited the couple that day, a sheriff's community service officer had already tried to find a solution, according to the report. The officer suggested the use of home health care workers and planned to contact the Florida Department of Children and Families for help if the couple couldn't make arrangements on their own.
Siebert found the home "impeccably kept, and clean" and Khalid Mahmud "well-spoken and articulate." The couple told the deputy about the problems they have with home health care service.
"It appears that Mr. Mahmud is using Hillsborough County Fire Rescue personnel, via (911) to possibly avoid having a caretaker in the residence while his wife is at work," Siebert wrote.
That violates Florida law, which forbids the use of the 911 system "in an effort to avoid any charge for service," he wrote. The crime is a first-degree misdemeanor punishable by up to a year in jail and a $1,000 fine.
Siebert took his findings to Bob Petschow, an assistant state attorney with the Hillsborough County State Attorney's Office.
"It is Mr. Petschow's opinion that there might be a violation of state statute, but he would not seek prosecution for the misdemeanor charge if it was presented to him, due to the circumstances," Siebert wrote. "He also believes that public opinion would not be favorable towards the Sheriff's Office if charges were filed against Mr. Mahmud."
That opinion hasn't changed, said State Attorney's Office spokesman Mark Cox.
"We certainly understand the frustration of the EMS people who have responded there so many times, but at the same time we have to factor in this gentlemen's age and health," Cox said. "The common sense thing to do is get social services in there to help them without criminally charging an elderly, handicapped man.
"We as a system need to be compassionate."
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Citing medical privacy laws, county officials declined to speak in detail about the couple's case or what services the county has offered to help.
"We are going to continue to work on this with all of the agencies involved to reach a resolution that works for everyone," county spokeswoman VanDyke said.
But it's unclear what that solution might be.
Someone in Khalid Mahmud's position can seek assistance from the county's Department of Aging Services, but neither the county nor the state offers what the couple say they need: on-call assistance.
Many clients in his position use adult diapers, which the county provides free of charge for eligible residents, said Agatha McDougle, community services program manager for aging services.
"I don't know anybody that does on-call (service) unless it's private pay," she said. "The thought of using (diapers) is not necessarily appealing but we have so many clients who receive those types of supplies. I'm not sure what else would be offered unless you're in an institution. But our services aim to keep people in the home."
Diapers are not going to work, Khalid Mahmud said.
"I'll be all dirty," he said.
The Mahmuds are an extreme example of "frequent fliers" and they're a "huge problem" for first-responders, said Wolfson, the professor of medicine and public health at USF.
"They get these kinds of calls all the time, and they can't not respond to the frequent fliers because they don't know if the person collapsed on the toilet that day," Wolfson said.
The country's health care industry is not equipped to provide on-call service for cases like Khalid Mahmud's, Wolfson said. There aren't enough nurses and home health care aides, and there isn't enough money to cover the costs.
But technology for the disabled is improving, the professor said, which will be critical for disabled veterans and aging baby boomers.
"It's only going to get more complicated as the aging population requires more assistance," Wolfson said.
For now, it seems, the Mahmuds will keep calling 911.
"We do not want to bother anybody," Rashda Mahmud said. "We just want the proper help."
Times senior news researcher John Martin contributed to this report. Contact Tony Marrero at email@example.com or (813) 226-3374. Follow @tmarrerotimes.