Turning the Tide, One Call at a Time

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View full size image of Two first responders with CHAT check on a man lying on the ground near a homeless camp under a freeway overpass. They are taking vital signs to see if he is OK.

Portland Fire & Rescue's CHAT/MOUD crews race against the clock to stop people dying from fentanyl and other drug overdose. They circle back later to help users break the cycle of addiction. [Photo shows CHAT responders Olivia Brant and Zach Wannamaker checking on a man at a homeless camp.]

CHAT responders Steve Manos and Dale Montgomery respond to a 911 call in CHAT 89, with a lift from a dragon named Smok.

The call came in at 12:34 p.m. on a chilly February day.

Suspected overdose. Adult male. Homeless camp in NE Portland, near the onramp to the Fremont Bridge.

As the details came crackling over the radio, EMT Steve Manos dialed up the coordinates while paramedic Dale Montgomery flipped on the lights and stepped on the gas of the red Ford pickup. Sirens blaring, CHAT 89 was on its way.

Three minutes and 31 seconds later, they pulled up to the camp, tucked along an anonymous stretch of cyclone fence. One of the campers pointed the way. Brushing past the thorny bushes, they found the man sprawled unresponsive on the ground, halfway out of a ramshackle tent, his face turned toward the drizzly sky. His skin was gray.

Manos and Montgomery set to work. In an overdose, every second counts.

A vital mission

Overdoses claimed 642 lives in Multnomah County last year, the vast majority of them involving fentanyl. For comparison, overdoses killed roughly 3 times more people than Alzheimer's, 4 times more than suicide, and 16 times more than traffic crashes.

CHAT's mission is to bring that number down.

CHAT stands for Community Health Assess and Treat. It's a specialized team created by Portland Fire & Rescue to focus on overdose calls. (CHAT also responds to other medical calls that don't need a fire engine and crew.) As part of its novel approach to overdose response, CHAT has also pioneered a groundbreaking program known as MOUD (Medication for Opioid Use Disorder).

MOUD (pronounced "mood") has two goals. First, save lives by responding to drug overdoses. Second, help those users who they just revived by offering them support to quit - if that's what they want to do.

"Those first few hours are crucial," Montgomery says. "Our goal is to reach them in that window. Most of them don't want this addiction, but they feel trapped. We can offer them a way out."

A second chance

As they knelt down to strap on an air mask, Manos and Montgomery heard a short, shallow gasp. It's a symptom called agonal breathing, derived from the Greek word for struggle. The overdose shut down the man's respiratory drive, starving him of oxygen. Now his brainstem was desperately fighting back, sending frantic nerve impulses to the lungs to snatch a mouthful of air.

The CHAT team works by the rule of threes. On average, the human body can survive three weeks without food, three days without water, and three minutes without air.

Agonal breathing can extend that deadline, like a soccer referee adding stoppage time before the final whistle. That gasp meant that this man might still have time on the clock. Montgomery started giving him air, pumping it deep into his lungs. The seconds ticked by. Then his eyes fluttered open. Fortunately, another camper had given him several doses of Narcan before the crew arrived on scene. Without that, he might not have survived.

Dante (as we'll call him) had regained consciousness, but he was in rough shape. The Narcan had put him into acute withdrawal. His heart was racing and his pupils were wildly dilated. He was sweating and shivering and soaked to the bone.

Most distressing of all, he was consumed by a profound, relentless ache, a physical craving for the drug that had almost just killed him.

Fortunately, the CHAT team came prepared for this scenario. They gave him buprenorphine -- a drug that binds to the brain's opioid receptors, easing the symptoms of withdrawal and blocking the cravings. For six precious hours, Dante would have a chance to make decisions without the ravenous hunger for fentanyl overwhelming his rationality.

Kneeling in the dirt, Montgomery asked him what he wanted to do.

A faster, better way

(Left to right) Paramedic Dale Montgomery, CHAT program director Michelle La Vina, and EMT Steve Manos work to bring down the number of lives lost to fentanyl and other drugs. The CHAT team responds to overdose calls and calls that require medical attention, but may not need a visit to the ER.

CHAT's approach to overdose calls is shaped by a key insight: Traditional 911 responders can bring you back to life, but they don't have much to offer immediately afterwards.

Firefighters can revive you, but after that, they're on their way to the next call. Ambulance crews can revive you, but their primary job is transporting patients to the ER - and ironically, many overdose survivors don't need (or want) to go to the ER.

"What they need is support," Montgomery says. "To escape the treadmill of addiction. They need someone who can help them through this crisis and circle back."

As the fentanyl epidemic ramped up, CHAT partnered with HealthShare of Oregon, CareOregon, Multnomah County, the Oregon Poison Center, and Central City Concern to launch the MOUD pilot in 2024.

The idea runs like this. Get there fast. Revive the patient. Offer them buprenorphine on the spot, to block the withdrawal symptoms. Help them get into shelter. Connect them with drug treatment. Circle back with aftercare over days, weeks, and months to check in and provide the support that is so vital to helping them piece their lives back together.

This approach has several benefits. It improves response time, which is the greatest indicator of life-saving success. It frees up firefighters to respond to other life-threatening emergencies. It frees ambulances for cases that truly require transport to a hospital. And it diverts patients from overstretched emergency rooms that do not offer the services these patients need.

Recognizing these promising results, Sen. Ron Wyden and Sen. Jeff Merkley obtained $1.5 million in federal funding to support the program. "This project saves lives and gives people a second chance," Mayor Keith Wilson said. "We are lucky to have advocates like Senator Wyden and Senator Merkley who understand the potential of projects like MOUD to help our community recover from the devastating impact of fentanyl and other addictive drugs."

One step at a time

CHAT responders Steve Manos (left) and Dale Montgomery (center) circle back to check in with Dante near a safe rest village.

Dante stands in a parking lot, wearing an oversized leather jacket and an orange watch cap with the tag attached. His boots are too big and his socks don't match. He is gulping down a packet of instant oatmeal spooned from a paper cup. He may look ragged, but he lights up when he greets Manos and Montgomery.

"It makes me feel good to see them," he explains to a bystander. "They've been awesome."

When he was revived, Dante told the CHAT crew that he wanted to quit fentanyl. They found him a place in one of the City's safe rest villages, where he has a tiny home with a door he can lock. They connected him with drug treatment at the Blackburn Center in East Portland. He goes there every day. "I want to get out of all those drugs," he says, "I don't want to take them no more."

Dante has a long journey ahead. He needs a lot of things right now: shoes, socks, underwear, glasses, housing, a gym where he can practice his martial arts. Most of all, he needs a job, so he can take care of his elderly stepfather. "He's the only father I've ever known," he says, wiping away a tear with his sleeve.

Manos and Montgomery brainstorm ideas with him. Take care of yourself first, they say. Make sure you're stable before you take on more responsibility.

"Thank you," Dante says. "You're my heroes."

Montgomery reaches out to shake his hand. "Well, you know something, Dante?" he says. "You're my hero."

Learn more about CHAT

See CHAT Overdose response dashboard