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Vital Signs: Care in Midair

FROM THE NOVEMBER 1998 ISSUE

Vital Signs: Care in Midair

A difficult procedure, a helicopter in terrible weather, and a patient's life on the line.

By Pamela Grim|Wednesday, November 10, 1999

There was a chance we could save Mr. Prodham--if our buckinghelicopter wasn't flung out of the sky first.

WE WERE AT 2,000 FEET and dropping fast. The flight nurseand I fumbled with our harnesses, preparing to jump out. I was the helicopterphysician on duty, and we were rushing to pick up a critically ill patient in asmall hospital about 150 miles away. We had to move; the weather was closingin.

Skip, the pilot, canted the helicopter toward one of thehospital parking lots. We were to unload hot--that meant we had to jump outwith our equipment just as the helicopter touched down and run like crazythrough the propeller wash and rotary roar. Already the guards at the hospitalentrance were being hit by the wind from the props. Their coats were blownopen, and one of them lost his hat.

"You have 20 minutes," said Skip as he jockeyed usdown. He couldn't just say it, of course; he had to use his helmet'smicrophone. The rotary blades made too much noise. All our monitor equipmentfor the patient had to be electronic with visual output only. Our regularstethoscopes were useless.

The helicopter struts touched down with a bounce."Go," Skip shouted through his mike.

I opened my door, grabbed two of the monitors and duckedout. Venetra, the flight nurse, was right behind me.

The attending physician had already told us about thepatient. It was a heartbreaking case. Two weeks earlier Kevin Prodham had had amassive heart attack. Since then he'd had every complication known: bloodclots, sepsis, renal failure, liver failure. Most patients would never survivethis, but Mr. Prodham was only 42. He'd been a healthy, active businessmanuntil two weeks ago. "He has kids in grade school," one of the nursestold me as we headed for the intensive care unit.

I winced when I saw him. He looked like a drowned man,bloated from the collapse of his circulatory system. He was on a ventilator,with leads and monitors and probes going everywhere.

Venetra began setting up the monitoring equipment while Iflipped through the patient's chart. For the past 24 hours, his oxygensaturation had been less than 70 percent. His blood pressure, despitemedication, had gone south early this morning and stayed there. He wascomatose; tests of his liver functions were nearly incompatible with life, andhe probably should have started dialysis the week before. This man was close todying.

I checked my watch. We had about 15 minutes. First we had toswitch all the pumps and monitors from the hospital equipment to our speciallydesigned "helicopter proof" ones. Because the helicopter was notpressurized, the pumps had to operate at varying ambient pressures. And theyall had to have visual alarms because we couldn't hear anything. Then we had tomove the patient over to the helicopter gurney and disconnect him from theventilator. The hospital staff had already inserted a breathing tube into his airway;throughout the flight we would have to pump air into his lungs manually, usinga device called an Ambu bag.

I was worried about the weather, though--within fiveminutes, I was signaling Venetra. We were taking too much time. She ignored me;a slipup with an IV line or a pump set at the wrong speed could destroy anyother attempt to save this man's life.

Finally we were ready. We trundled down the hallways. Thepatient's wife did not let go of his hand until we reached the door.

It was colder now, and the sky looked thin and gray. Maybethe wind had picked up, but with the helicopter going, it was hard to tell.

We slid the patient into the back of the helicopter. He wasa big man, and tall. His feet stuck out over the end of the gurney, nearlytickling Skip's ears. We would have to do everything back here, and if hedeteriorated, we'd have to stabilize him. That meant IVs, chest tubes, centrallines--all difficult procedures on the ground, much less at a thousand feet and140 mph. But I had faith in Skip. He had trained as a military pilot in Southeast Asia. In Vietnam, he told us, there wereonly two kinds of helicopter pilots: good ones and dead ones.

We took our places for liftoff. I buckled myself into a seatby the patient's head. Skip contacted base. "This is Air TransportOne," he said. "We are lifting off at 4:33. Four souls onboard."

"Souls." Skip always said that. I patted ourpatient, hoping his soul was still connected to his body.

We lifted off. I could feel the helicopter slip sidewayswith the gusting wind, recover, then slip again. We kept rising and thenleveling off. Rain started pricking at the windows. The thunderclouds lookedominous.

The ride seemed to be getting bouncier. I sat pumping theAmbu bag, trying to keep my balance.

Skip came on the intercom: "I'm going up another 500feet. It should be smoother up there. How's the patient?"

"Alive," I said.

"Barely," Venetra added.

"You guys buckled in?" Skip asked, and as he did,a gust of wind hit the helicopter. I fell against the window as the entirehelicopter swung sideways. I ended up looking straight down at the farm fields1,500 feet below. It was the last view I saw of the ground. We were enfolded ina cloud of gray mist. Then we ascended and just as quickly dropped back down.Venetra and I were being tossed around like little dolls.

We swung sideways again, so far askew that the helicopterblades were almost directly to my right. "We can't stay aloft likethis," I thought in the second we hung that way. With another gust we wererighted. I had been in the bumpy helicopter before, but it was never anythinglike this.

It was worse than any roller coaster. The downs weren't likethose of going down a hill; they were those of dropping from some great height.As I reached out to hold on to the leather strap above me, I realized my handswere shaking.

"Should we go back?" I yelled at Skip through theintercom. There was a long pause. Skip must have contacted base with us out ofthe circuit. Finally he came back on. "That's a negative. Base statesweather worse behind us."

I was struggling to pump the Ambu bag to breathe for thepatient, but I kept being thrown back into the window. Then the patient showedthe only sign of life I saw during the whole trip. He coughed. AS he did, theAmbu bag collapsed in my hand. The patient had extubated himself.

"We lost the airway," I yelled to Venetra throughthe microphone. Unless we quickly slipped in a breathing tube, he couldsuffocate in minutes.

This had happened to me once before. We ended up landing ina cornfield long enough for me to get a new endotracheal tube in. I wasn'tgoing to risk an intubation in the air that day, and then the helicopter was arock compared with how it felt now.

"Skip, Skip," I shouted into my microphone."The patient's extubated himself. Can we land for a few minutes?"

There was a long pause. "That's a negative, doctor.Weather conditions do not permit." Skip had never called me"doctor" before.

Venetra had unstrapped herself; she wedged her knees underthe patient cart and prepared Mr. Prodham for a second intubation.

Now I had to get out of my seat belt. As I reached for mybuckle I realized I was scared--not just nervous, but deep-in-my-bonesfrightened. It took an act of conscious will for me to open that metal clasp.Immediately, I was airborne and then slammed down to the left, against a smallcabinet. I was too scared to know whether I'd been hurt. I inched my way to thehead of the cart and groped for the box containing the intubation equipment Igrabbed a laryngoscope--the tool we use for introducing the breathing tube intothe airway. As I did so we made another ascent--gentler this time, but stillenough to spill the contents of the box everywhere.

"Give me a tube," I said to Venetra. She gropedaround on the floor, looking for the right size. She found one and handed it tome. I opened up the laryngoscope and slid it into the patient's mouth. I triedto get the tongue up and out of the way. My heart sank along with the nextsickening drop of the helicopter--I had forgotten how bloated with water thepatient was. His tongue nearly filled his whole mouth. How was I going to see?

I looked up at Venetra. She looked green.

"I'm airsick," she said. "I'm going to throwup."

"Well, don't do it on the patient."

She grabbed a bag out of the closet and stuck her headinside.

The helicopter took another shaking plunge. As I tried tohold on to the side of the cart, the laryngoscope rambled out of my hand. Ifell after it and caught it as I landed facedown on my seat.

This man is going to die now, I thought; no one as sick ashe is could survive this. But I would get him reintubated, no matter what. Irighted myself and edged back to the front of the cart.

Then Venetra was holding the Ambu bag, ready. I snapped openthe laryngoscope and slid the blade into the patient's mouth. Please, I said tomyself. Please.

I saw for a moment all the landmarks--the epiglottis andbeyond to the vocal cords. At least I could see past the tongue.

The helicopter lunged again, and the patient's face rolledaway. As I tried to pull him back into place, I thought of a helicopter crashI'd seen in Colorado--thedoctor in the back with two shattered hips. I knew those injuries. And I couldsee in the wreckage up front the pilot and the nurse hanging limply in theirharnesses. I could hear the wind coming through the shattered glass and seethose two figures sway. They had pushed the weather--trying to reach anunstable patient in some far-off clinic.

The helicopter bucked again, but this time the movementworked for me. I was flung forward, my hand jerking up, and the tube, as if ofits own accord, slipped into place cleanly, right between the vocal cords anddown into the airway.

My first thought was, Maybe there is a God.

I straightened up. "I'm in," I shouted to Venetra."I saw it."

We dropped again. I struggled to hold the tube in place. Wemay be about to die, I told myself, but this man will not lose thisendotracheal tube.

Another ascent and then the rain stopped. For a moment ourflight became steady and fairly quiet. Then came a pounding on the roof and thewalls of the helicopter. It sounded like someone was beating the helicopterwith a baseball bat.

"What is that?" I shouted at Venetra.

"Hail," she said. "That's hail."

We sat there, wedged in place, while all around us the metalseemed alive with the force of pounding rocks. I looked back down at mypatient. I had no way to listen for breathing sounds, so I had to trust thatthe tube was in place. As I pumped air, it seemed his color was better. Hispulse stayed rock steady at 75.

Suddenly the helicopter lit up as if it were on fire. Anexplosion, I thought. We've exploded. Then I thought, that can't be, I'm stillalive. I looked out the window.

"Lightning," Venetra said.

The intercom buzzed again. "Hang on," Skip shoutedto us. "I think we're through the worst of it." And then, as suddenlyas it started, the helicopter stopped bouncing around and settled into itscustomary glide. We broke free from the gray clouds, and the helicopter filledwith evening sunlight.

The patient's heart rate was 75.

When we landed, Skip stepped out of the helicopter, lookingshaken and pale. He stood at the edge of the helicopter pad, smoking acigarette, his head bowed, as if in prayer. When he looked up at me, he waswearing the same expression I had seen on doctors who had just lost patientsthey didn't expect to lose.

"I pushed the weather," he muttered as I pattedhis shoulder. "I can't believe how I pushed the weather."

"Well, we made it," I told him. "It's a happyending...."

And there was another happy ending. Mr. Prodham responded totherapy, the liver failure reversed itself, and his kidneys perked up enoughfor him not to need dialysis. I stopped by the ICU every day to see how he wasdoing. His wife was always sitting there, holding his hand. One day I found heralone in the waiting room, crying because her husband was doing well enough tobe taken off the ventilator.

"It's a miracle," she said, gripping my hand."All this has been a miracle."

"Yes, yes," I said, squeezing her hand in return.I didn't tell her that during our wild ride I saw no evidence of a miracle.Just fear, hard work, and--well--maybe a little divine nudge to the elbowduring the intubation.

Or maybe that's not true. Maybe something did hint at themiraculous. It was at the end of the flight, after we had cleared the clouds.First it was sunset, but as we flew east the sunlight disappeared, and it wasnearly night when we got back to the city. We were flying at about 1,000 feet,and at that height you could see the grid of streets below, lined withdollhouses and marked by streetlights. The lights were laid out before us,brighter and brighter until they formed a solid mass of light that edged theblack ocean. The skyscrapers were to the north and they, too, were marked outonly by light. The real buildings, the steel and concrete, were asinsubstantial as the night.

As I gazed out across the city, I wondered if Vietnam feltlike this: you rode like bats out of hell, through the land of death anddestruction, suffering everywhere you looked, until at some moment, after youbroke free from the ground fire, you'd see as you looked all around you howbeautiful the night sky was.

PAMELA GRIM (Vital Signs, page 44) is an emergency medicinephysician and a research scientist in Cleveland."In the ER, you never know if you've done the right thing," saysGrim. "You come home and think, `Should I have done this? Should I havedone that?' In my stories, I'm not the hero."