Spittin' Image

I was born there, and I still lay claim to her as my original home. Plucked, up and away, to Bellingham, from Billings, when I was just four; the subsequent biannual drives, there and back, are etched deeply onto my memory. Montana is vast, and driving for hours, between points just inches apart on a map, lends a scale to the Earth that still inspires both awe and a little terror. Sawtooth mountains reach above the weather, ever on the horizon, as you slowly creep across the valley floors. There is no dust, no water in the air, and when you crane your neck, peering straight up, your gaze penetrates the stratosphere, to the edge of space.

A promotional pamphlet, published in 1895, touted Montana as The Treasure State, a reference to her abundant gold, silver, and especially copper, production. This name stuck until 1961, when, life imitating art, a representative of the state advertising department asked A. B. Guthrie, the author of The Big Sky, at his remote ranch, permission to use the title as a catchphrase to promote tourism. He reportedly agreed on the spot. The Big Sky sounds more like an ancient, reverent name for a holy place than a best seller about the fur trade, and for years I assumed it was. That Guthrie's editor suggested the title shouldn't prejudice your appreciation for the poetry in the words.

But the sky. The blue, blue sky. So deep, so rich, so full of promise, serenity, happiness, optimism, and over-arching love. I have various snapshots: bucking hay, driving the Beartooth, Christmas '76 - the sky is exactly the same, a perfect indigo that grabs me by the glands and whispers, "Welcome home." The landscape in Montana is writ with the American mythologies of Cowboys, Indians, of liquor and tobacco. The road to my Grandma's house is writ with irony, plastered onto a billboard.

This is my confession: I am a tobacco user. Not cigarettes, not anymore, not for a long time- I flirted with those in college, and gave them up easily enough when a certain young lady expressed interest, although I flirted with them for a while during the divorce - a sort of a relational bookend. I'm talking smokeless tobacco... the rough sawn, hard luck, boom town cult of chewin' tobacco. Chaw. Snoose. Yuck, yeah, right. Gross.

The fire service is thick with chew enthusiasts. More than you might expect. For every firefighter you see with a Cope ring on the back pocket of his jeans, there's several that have a habit they maintain covertly. The rationalization goes like so: "At least I can run the stairs." And they can. It doesn't affect their pulmonary function; they're not inhaling tar and all the lung-clogging crap associated with burning tobacco. But it will probably eventually affect their health.

Some guys always have a dip in, but it might be so small as to not require the signature spitting. Others just suck it up and swallow the poison. Might be the spouse, might be a private shame, but people, in general, frown on the whole spitting thing. Which I don't quite understand. Smoking exposes other people to your smoke when you exhale, but spitting in a coffee cup, or even on the asphalt, can be pretty benign when gracefully executed. The first time you empty a garbage can full of someone's tobacco spit, however, is a memory to savor and share.

At the state fire academy, I took a righteous stance against my fellow recruits' use of chew, and composed an anti-dippin' cadence. When they sang it I convinced myself that I was helping them, but no one quit dipping.

tell me when you've had enough /
eatin without teeth is rough /
why don't you have a nuther snuff?

the scariest thing I ever saw/
was the cancer that killed my grandpa/
why don't you have a nuther chaw?

I can't tell you what to do /
but I don't think you'll be able to sue /
why not have a nuther chew?

'fore you go I got a tip /
I don't think you need your lips /
why not have a nuther dip?

My friend, Dave, has probably been dipping for thirty or more years. He's my age, but only I started chewing tobacco less than a year ago, spurred by the boredom and privacy of working on my rental home. Ennui and a convenient 7-Eleven conspired to deliver a tin of Kodiak to my mucous membranes. I've known dozens of smokeless tobacco, chew, users, but I never understood the compulsion to pack the dip in the lower lip until I tried it.

There is a learning curve, and I advise the curious to avoid dipping while driving, during the early stages of skill acquisition. Retching in a cup, at sixty MPH, eyes streaming, is probably slightly more dangerous than talking on a cell phone while driving - with your eyes closed. -with no hands. -from the passenger seat.

Remember the blue, blue, blue, Big Sky of the Treasure State? That's the color of nicotine. That's the promise, the optimism, the warmth, friendship, and love that the drug vowed to me. For a while. Then I started to dip more, and it never again lived up to the initial promise of happiness. The tin of chew virtually buzzed in my pocket, reminded me of the lost euphoria, like fading Kodachrome vacation slides. The indigo existed outside my daily experience, and to even conceptualize the indigo required nicotine. Indigo became unobtainable. The world started to render in shades of brown, tans, washed-out slate tones.

I missed the indigo, and so I haven't had a dip in almost two weeks. The physical pain of nicotine withdrawal is really just a few days discomfort: headache, tension, grouchiness. Ibuprofen and beer help. So does exercise. It helps that dipping is a private endeavor; there's no second-hand smoke to taunt you when others indulge around you. I found it easy to refuse the offers of a shared dip. When asked if I was "packing", I explained how I was on the wagon, and had none to share. Don't come round here, no more.

I have my motives for staying off tobacco, but, foremost, stuffing carcinogens into my mouth seems ill-advised, given my family's history of cancers. I don't want my kids to take up tobacco, in the way kids inherit their parents' behaviors and values. And I don't like that I respond so easily, so willingly, to a nagging, whining addiction voluntarily carried in my pocket, with my change.

Lost and Found

Why not Velcro? The thought occurs to me once again, in this urgent moment. I'm fumbling with the zippers on top of the red oh-two kit, knowing the woman on the carpet needs to be ventilated. Right now. I've pulled the oxygen cylinder from the compartment in the kit, spun the valve on the regulator open. I'm ripping open the plastic bag containing the bag-valve mask, but the tubing is secured with a "quick release" tie that does neither. Randy has started compressions, but my world is reduced to this act of wrestling with the equipment in my hand.

The paramedics arrive right behind us, kits in hand. "Get oh-two and a BVM going!"

The BVM is finally assembled, and I'm trying to get air into our patient's lungs. Her head is between my knees on the stained carpet, and I am holding her head back and up, to straighten her throat, forcing the mask against her face with my fingers. Her cheeks are puffing out with each squeeze of the bag, but I see no chest rise under Randy's hands.

The same medic wants to know if she's getting air. "Randy, hold off for a sec, I want to see if this is working." He rears back from her chest, I squeeze the bag, her mouth inflates, nothing's getting in. Crap. "I need an OPA!" The oropharyngeal airway is the quickest way to get the air past her tongue, to her trachea, before one of the medics gets to the task of tubing her. Randy is pumping her chest again.

Off to my right, I see Brian, our newest medic, the man running this code, twist and pluck something from his kit. Engine 43 is on scene for manpower, and he hands Mike the OPA kit. After ripping the zipper open (another zipper), Mikes's comparing the length of an OPA against her jawline, ensuring we use the best size for her anatomy.

I open her mouth to find toothless gums. Ah, shit. Dentures? I scoop my gloved finger into her mouth, but her false teeth are not there. I imagine them bobbing in a glass of water beside the bed where we found her. I'm holding her mouth open like a trophy trout, and Mike is twisting the OPA into place, past the back of her tongue. The tabs are supposed to rest against her incisors, keeping the device from sliding deeper into her throat, but without teeth, it will just float in place. Good enough.
Randy's watching us, and pauses his chest compressions long enough to verify the tell-tale rise of her chest when I squeeze the bag again. I can literally watch the pure oxygen inflating her starving lungs. "Good air!" I announce to everyone.

I look around, timing the delivery of life-saving breaths to Randy's rhythm from the corner of my vision. Brian is almost done with the IV, and Eric, the other medic, has already slapped the patches on her chest, is taking a 12-lead, a recording of the this woman's heart's electrical activity.

Two minutes

Eric analyzes the patient's cardiac rhythm. We all cease what we're doing and move back from our patient, isolating ourselves from her. The monitor indicates that a shock is warranted. "Shocking." Her body barely twitches when he pushes the button. "Resume CPR." We start our second round.

Brian finishes hooking up the IV, and moves to the head, Eric pushing a syringe of drugs into the port on the plastic tubing. "Stop bagging, I'm getting the tube." He has the laryngoscope in one hand and an endotracheal tube and stylet in the other. He rips open the stylet package, inserts the flexible wire into the tube, and lays at her head, on the living room floor, on his stomach. He quickly shapes the tube into a graceful curve, the inserted wire holding the shape. Brian cranks her mouth open, the blades of the scope slips past her tongue.

He's looking through a fiber-optic eyepiece. "Cords!" I've never heard this announced by a medic inserting a tube, but I assume he sees her vocal cords, a critical factor in the successful placement of an ETT. It's in and Brian is trying to pull the stylet out of the tube, but his fingers are slipping on the plastic, threatening to pull the whole thing back out. I grab the loop of the stylet, as he holds the tube with both hands, and the wire comes out easily. A syringe inflates the cuff at the tip, and it's in.

Before the BVM is connected to the tube, Brian slips a short collar over the end. This collar is connected by a long, spaghetti-like hose to the monitor, screwed into the capnography port. The monitor generates a wave form, either on the screen or a printed chart, allowing the medics to observe their interventions' effects on the respiratory efficiency of the patient. The bag-valve assembly slips onto the collar, and I commence squeezing. Brian borrows my stethoscope, verifies that the tube is properly place.

"That's two minutes." My captain is timing this code with my watch's second hand, the clasp of which I had struggled to release through my glove. It's on a doily-draped table, and he's been glancing at it, between notations on the patient report.

Four minutes

Brian calls to stop CPR. "Check for a pulse."

Several arms reach for the woman's neck, competing for the task of palpating her carotid artery. Randy wins, "I've got a pulse..." His fingers rest a moment on her throat. "Sixty-four."

Eric turns to address the husband, perched on the couch across the room. He was in the kitchen, hyperventilating, when we arrived, and I don't know how or when he moved past us, to his current vantage point. "Sir, we have a pulse!"

"Is that good?"

"Yes, my friend. That's very good."

"I See Drunk People..."

"Hey Buddy." I shake his shoulder, firmly. "HEY BUDDY!" He's slumped in the stall, pants down, on the shitter. A small gash seeps on his forehead, probably from hitting his head on the toilet paper holder. A laptop case lies at his feet. Outside, behind me, several police officers and my crew chat in the train station restroom. My right hand seeks a radial pulse... ah, there it is. Not dead. My left hand cracks the ampule of ammonia inhalant, soaking the wrapper with pink foulness. I hold the sachet under my patient's nose for a long moment. He gently bats at it, the vapors plumb the depths of his addled mind. We call them Silver Bullets, the only tool for the job of rousing the poisoned, intoxicated, unresponsive zombie. At last, the odor finds purchase on his brain and pries the stupor out of the way, like a heavy door.

"Cut that shit out, man!" He swats again, this time his hand is pushing the ammonia away. I pull it away for a second and then firmly press it under his nostrils.

"Wake up. What's your name? Talk to me."

"Whatdaya want?" His eyes are open, unfocused, he grabs my hand. I withdraw, replaced by a police officer. A rambling conversation ensues. "Oh, a few beers," he allows. Humorless chuckles from the crowd. The station is closed. He is drunk, broke, homeless. A plan is formulated. I'm gloved up, closest, least senior; it falls to me to hoist his drawers, get him moving to a bench outside the men's toilet. This is, in fact, more difficult in practice than theory might predict.

He can barely stand, his pants are still fastened, belted, and catch on his skinny hips. He sways, I lift and steer him past urinals, sinks, out the door. His bare ass is covered by his coat, but I keep him at arm's length anyway. If he collapses I'll keep his head from hitting the tiles, but I will not get poop on me.

He's on a bench now, and I wonder if the cleaning lady who found him will scrub the oak after he's gone. The police are asking him questions again, while I collect vital signs. Does he have a medical emergency? Where does he want to go?

He wants a place to sleep, and the fire department is not needed. I pack up my kit, snapping the case closed, clack, clack. We stride out the doors, into the autumn night, to our idling fire engine.

Several times a day, miscellaneous fire department vehicles are dispatched to man down calls, usually called in by a well-intentioned driver with a cell phone. These alarms are routed to Fire instead of Police, despite an historical record demonstrating "man down" equals "public intoxication." Aid cars, engines, ladder trucks roll up on the address, searching for the patient, taking clues from the information relayed by the (frequently confused) passerby. Frequently, no patient can be found, or a blast from the air horn rouses them from their nap, and they move on, to seek a more private retreat. But, more often, we find ourselves standing above a drunk, shaking him by the shoulder, reaching for the trusty Silver Bullet.

In addition to blood pressure, pulse, and respiration rate, we assess our patient's level of consciousness, as a matter of course. If he answers questions appropriately, he's alert. As his LOC decreases, a response may require shouting or painful stimuli. Genuine unresponsiveness, an emergency in itself, makes the situation, instantly, more serious. Our assessment becomes more critical, and, in certain circumstances, perhaps a tad cynical.

It's not unheard of, to be called for a Police incident in which the subject suddenly goes limp, feigning injury or illness. In EMT school, we were taught to grind our knuckles vigorously into the sternum to elicit a response from the verbally unresponsive. It's old school, and requires no special skill. The sternal rub might reveal the BS in the BLS (Basic Life Support), but it looks bad when executed properly. "Why would that nice firefighter hurt that poor man like that?" an on-looker might ask. Try doing it to yourself, and see how much effort it takes to provoke a grimace. A better technique is to place your fingers behind the jaw, at the neck, and dig a finger into the hollow on both sides. This is innocuous, appearing to the casual observer as a tender, caring touch. Alternatively, a limp arm can be lifted over the patient's face, dropped, and observed. The arm of a patient faking coma will not hit his face, but falls adjacent to his head.

We go on these calls on the off chance that a real medical emergency has occurred. Last night we were dispatched to see a woman at a bus stop. "Unconscious, breathing, pants around knees." We arrived to find her draped sideways over the bus stop structure, bare butt in the air. Handing off an ammonia sachet, I sprinted to fetch a blanket from the rig, while Randy, our driver and former paramedic, checked her carotid pulse. I returned to find my captain and Randy lowering her onto the sidewalk. I covered her nakedness with the blanket and Randy set up the bag valve mask to assist respirations. He asked for an oral airway, a curved beam of plastic, "H"-shaped in cross-section, that keeps the back of the throat from collapsing, and closing off the air supply. She didn't gag on the device as it was twisted into position. That's a bad sign.

An empty bottle of vodka lay on the grass where her head had rested, and pills were found in her purse. Her clothes and shoes looked reasonably expensive, not the usual man down attire. Medics arrived, an IV was started, Narcan administered. One of the medics expressed doubt that the Narcan, a anti-narcotic, would have, with this patient, its magic effect. Sometimes, it sucks to be right. After they tubed the patient, I drove the medic rig to the ER, the engine following. We don't know what happened, we don't know her outcome. Seldom do we.

But, this I know: There will be man down calls. I make sure the kit is always stocked with barf bags and Silver Bullets.