Chapter 17: Air Ambulance

July 6, 1989, McKinley, Ohio

"What do you need, Doctor Casper?" I asked as Mary, Tom, and I entered Trauma 2.

"Doctor Wilson is in Trauma 3 for a chest tube and central line, so I need you to put those red scrubs to use and confirm my MVA needs an ex-lap for splenic rupture."

"Indications?"

"Abdominal pain, epigastric tenderness, Kehr's sign, tachy, hypotensive, strained respiration requiring intubation. The patient consented before intubation."

"Tom, ultrasound, please," I said.

"Be right back!"

"Mary, Kehr's sign?"

"Acute pain in the shoulder, usually resulting from blood in the peritoneal cavity in a supine patient with their legs elevated. Left shoulder referred pain is a sign of splenic injury."

"Differential?" I asked her.

"Diaphragmatic injury, kidney stones, and, in a female patient, ruptured ectopic pregnancy."

"Very good. You perform the ultrasound."

"Uh..."

"You can do it," I said. "We'll all see the image."

Tom returned with the ultrasound unit, and I walked Mary through the procedure.

"What do you see?" I asked.

"I have no idea what I'm looking at," she said.

"This," I said, pointing, "is his spleen, right below his left lung and to the left of his liver. And this," I pointed again, "is free fluid around the spleen, indicating bleeding. We could do a peritoneal lavage to prove it's blood, but I think that's wasting time. Mary, call up and say we have a surgical case — ex-lap for probable splenic fracture. Tom, we need an orderly."

"Thanks, Mike," Ghost said, handing me the chart.

I made my notes, signed it, and handed it back.

"Somebody call for a surgeon?" Doctor Mary Wilson asked, coming into the room.

"Mike did the consult," Ghost said. "You were busy with the driver."

"Then I'm going up because they'll need two teams."

And if she was going up, that meant my students, and I couldn't scrub in, as I'd be the only surgical Resident available.

Twenty minutes later, Mary, Tom, and I were back in the ED.

"I thought we might get to scrub in," Mary said.

"Once Doctor Wilson said there were two surgeries, and she was going to scrub in, I knew that couldn't happen."

"Doctor Mike?" Nurse Tiffany, who was at the triage desk, called out. "Walk in chest pain."

Which meant they had to be seen immediately, with only someone transported by EMS having priority. I looked at the board and saw Trauma 2 was free.

"Tom and Mary, wheelchair, and bring the patient to Trauma 2. GO!"

I went to the nurses' station and asked for a nurse, and Billie followed me to Trauma 2.

"What's your name, sir?" I asked as my students brought him in.

"Mike Meyer," he grunted.

"Let's help him onto the table," I said. "Mary — EKG, monitor; Tom — IV saline and start a chart; Billie — nasal cannula, CBC, Chem-20, ABG, and stat cardiac enzymes."

We got Mr. Meyer onto the bed and I performed the primary exam while the others executed their tasks.

"How old are you, Mr. Meyer?" I asked after auscultating his heart and lungs.

"Forty-nine," he grunted.

"Do you smoke?"

"No."

"IV is in!" Tom announced.

"Do you consume alcohol?"

"A couple beers after work with the guys most days."

"When did the pain start?" I asked.

"About an hour ago, I guess."

"BP 190/120," Mary reported. "Tachy at 125; PO₂ 92%; EKG shows arrhythmia."

"What do you see?"

"The T-wave doesn't look right."

I looked up and saw she was correct.

"Inverted T-wave. Call for a cardiologist, please. Tom, get the blood to the lab."

"Right away!" Mary replied.

"On it!" Tom declared.

"What's that mean?" Mr. Meyer asked.

"That your heart has been damaged in some way. Just try to relax, please. We're calling for a cardiologist, and we'll give you some medicine to help. Billie, 250mg ASA IV push and sub-lingual nitroglycerin tab."

"250mg ASA IV push; sub-lingual nitro," Billie repeated.

The nitroglycerin brought down his blood pressure slightly and helped with the pain. About four minutes later, Doctor Shore from Cardiology arrived with a Third Year I didn't know.

"Shore, Cardiology. What do we have?"

"Hi, Pat," I said. "Mike Meyer; forty-nine; presented with chest pains; hypertensive; tachy; inverted T-waves on the monitor; murmur on auscultation. Administered ASA and nitro. Recommend cardiac echo."

"Thanks, Mike. Mr. Meyer, I'm Doctor Shore from Cardiology."

He proceeded to listen to Mr. Meyer's heart and reviewed the EKG.

"I'll take him on my service," Doctor Shore said. "Mr. Meyer, we're going to take you upstairs and perform an echocardiogram — an ultrasound of your heart — to get a better idea of what's going on. Mike, enzymes?"

"Ordered stat. We should have them momentarily."

"Kyle," he said to his student, "call for an orderly. Mike, I'll need him on a portable monitor."

"Tom," I said. "Switch to a portable monitor and escort Mr. Meyer upstairs."

"Will do."

I updated and signed the chart, then said, "Mr. Meyer, you're in very good hands. Mary, with me, please."

We left Doctor Shore, Tom, Kyle, and Billie with the patient.

"Mike," Angela called out. "Arm lac in Exam 6. Doctor Varma asked if your student could suture."

"Absolutely," I said. "Mary, this is all yours. I'll watch. Remember, identify yourself as a Sub-Intern and me as your supervisor."

"Got it!"

The arm lac was clearly a simple repair, so once Mary had explained what she was going to do, I left the exam room and saw Tom walking down the corridor from the elevators.

"Trouble?" I asked.

"V-fib in the elevator, but he cardioverted immediately. How did you know?"

"You were gone too long for a simple transport," I said.

"Mike?" Nicki, the clerk called out, "EMS two minutes out with a burn victim. It's a bad one. Doctor Casper needs your help."

"OK. Tom, let's go. Mary is suturing."

We gowned and gloved and hurried to the ambulance bay. I looked across the driveway and saw the slowly rising building that would be our new trauma center, but the paramedics arrived just a few seconds later, and I cleared my mind to focus on the patient who was about to be unloaded.

"Mike, if this is as bad as it sounds," Ghost said, "we'll stabilize, then you'll take him to the burn center in Columbus. You're qualified, right?"

"Yes, My EMS ride-alongs fulfilled that requirement. Why send me?"

"The problem is that if one of the senior Residents or Attendings goes, we'll have to call someone in, and we're short-staffed because Loretta is on leave until tomorrow, and Boyd and Fitzgerald are out sick."

"OK. I'll leave you Mary, even though she'll have a fit. She can do suturing and other basic procedures for which Tom hasn't yet been trained."

"Helicopter?" Tom asked nervously.

"Yes."

"They come off the assembly line with the single mission of killing all their occupants!"

"I can take Doctor Varma's third year," I said.

"No, I'll go."

The EMS squad pulled up, and the paramedic jumped out.

"Bad one, Doc!" he said as he moved to the back of the squad and opened the door. "John Doe, mid-to-late twenties, with third-degree burns on his arms and most of his torso; smoke inhalation; BP 90 palp; tachy at 130; PO₂ 90% on ten litres by mask with no cyanosis; morphine administered; IV saline."

That amount of burn coverage meant, based on the rough calculations, about 50%, and his chances of survival were around 60%, though with smoke inhalation, that number was likely generous.

"Mike, have them warm up the chopper. Tell Mary I need her, and the sutures will have to wait. Get ready to go because as soon as I evaluate him and get another IV into him, he's going to Columbus."

"Right away, Doc! Tom, come with me."

My first stop was at the clerk's station, where I asked Nicki to call for the helicopter, which she did. Next, I went to Exam 6 and asked Mary to step out.

"Doctor Casper needs you in Trauma 3 to help with a burn victim. Tom and I are going to take him to Columbus by chopper as soon as he's stabilized. I'll let your patient know you'll be back in a few minutes.

"Not to be a bitch..."

"I know, but we're short-handed and no disrespect to Tom, but you can be much more useful here rather than babysitting the patient on the helicopter. Go!"

"Yes, Doctor."

She left, and I went into the exam room and informed the patient that we had a serious emergency case and that Mary would be back shortly. We left the room and Nicki signaled me.

"Fifteen minutes," she said. "The crew is on their way to the pad. Burn center notified of an incoming patient."

"Thanks!"

I took Tom to the locker, where I gave him the same basic instructions I'd once been given, and I put on a red flight surgeon jacket while Tom donned a blue trainee jacket. We grabbed our helmets but didn't put them on, then headed to Trauma 3.

The patient had been intubated and now had two large-bore IVs for fluid replacement. The burns made an EKG impossible, and the pulse oximeter was on his ring finger, rather than his index finger, due to burns. And the room smelled of charred flesh, which caused my stomach to turn.

"Chopper will be ready in about ten minutes," I said, fighting the nausea.

"Full-thickness burns over his arms and torso," Doctor Casper said. "Tom, get Doctor Taylor, please. Drag him in here if you have to."

"Yes, Doctor," Tom replied.

He left and returned with Doctor Taylor about a minute later.

"What do we have, Ghost?"

"Male; late-twenties; 50% full-thickness burns; hypotensive and tachy; IV Ringers with dobutamine; intubated; minimal urine in the bag; he needs to go to the burn unit in Columbus as soon as surgery does an escharotomy. The chopper is warming up and I plan to send Mike and Tom. You'll need to formally sign off for Mike to fly solo. His EMS ride-alongs completed his requirements."

"Mike, let me have your procedure book, please," Doctor Taylor said.

I pulled it from my back pocket and handed it to him. He wrote on a blank page, signed it, and handed it back.

"You're cleared. I'll update the hospital records. Ghost, I think he should take a nurse as well. Kellie can go with them; she's a certified flight nurse from her Navy service. I'll let her know. She'll bring the drug box."

"What do we have?" Doctor Lindsay asked, coming into the room.

"Hi, Shelly," Ghost said. "50% full-thickness burns with pulmonary compromise. He needs an escharotomy."

"OK. Mike, put a gown over that flight jacket and assist, please."

Nurse Billie helped me into a gown and put a mask on me, and I stepped up to the table with Doctor Lindsay, who had been helped into her gown and mask by Nurse Jenny.

"Have you seen one of these?" she asked.

"No."

"We incise the burnt skin down to the subcutaneous fat and into healthy skin lengthwise, if possible. The goal is to relieve the constriction of his chest and allow for better respiration. When you cut, you need to take care to avoid nerves and veins. Watch and one of us will supervise you performing this in the future."

She made the necessary incisions, which only increased my nauseated feeling. I'd always heard severe burns were the worst, and now I was sure of it, and not just for the patient, but for the surgeon and other medical staff. The smell, combined with the sights and sounds of crackling flesh as she cut, was enough to induce nausea in anyone.

"Billie," Doctor Lindsay said, once she'd completed the procedure, "antimicrobial dressing, please. Vancomycin, 100mg IV push, then drip at 10mg/min."

"Vancomycin, 100mg IV push, drip at 10mg/min; antimicrobial dressing," Nurse Billie repeated.

She and Jenny quickly and efficiently set up the IV and dressed the escharotomy.

"50%?" Mary asked quietly.

"It's a rough calculation — 9% for each arm, 36% for the torso, 9% for head and neck, 18% for each leg, and 1% for genitalia."

"Thanks."

"PO₂ now 93%," Ghost said. "A slight improvement. Mike, your key number is his BP. Keep the fluids flowing, and keep the dobutamine drip going. The fluids and dobutamine should keep his pressure up. Increase the dobutamine if you see the pressure drop. If you need help, they'll patch you through the radio to us or the burn center."

"OK," I said. "Let's go."

Ten minutes later, Tom, Kellie, and I were buckled in, and the patient was loaded into the helicopter.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University," I heard in my helmet as the helicopter lifted off.

"Relax, Tom," I said, seeing his knuckles whiten as he gripped the armrest to his left.

"First time on a helicopter?" Kellie asked him. "Push the intercom button to talk."

The intercom button was only for the medical staff, with a separate button for the crew.

"Yeah," he said. "You were in the Navy?"

"I was a Navy nurse for six years. I flew on dozens of transport missions. My job was to assist the flight surgeon, as I'm doing now."

"Were you at sea at all?"

"Only in the sense that we flew over it. I wasn't permitted to deploy to a combat ship. Congress needs to get their thumbs out of their butts on that! My regular duty station was the Naval Hospital in San Diego."

"Get a BP for me, please," I requested. "You'll need to use the ankle, given the burns on his arms and the dressing."

She took the measurements and reported them as 110/80, which I adjusted, as ankle systolic pressure was anywhere from ten to twenty percent higher than brachial pressure. That meant his brachial pressure would be somewhere around 100/70, which was much better than when he'd first come in.

"No changes to the IV," I said. "Sats look as good as we could hope for."

It was 94%, and given his smoke inhalation combined with the circumferential burns, I doubted we could get it higher until his lungs recovered.

"Mike, can I ask why they didn't send an Attending?" Tom inquired.

"It's only required for cardiac cases," I replied. "And despite hypotension and tachycardia, the patient doesn't appear to have any compromise of heart function. In effect, we're acting as paramedics, and both Kellie and I have more training than they receive. Both pilots are paramedics as well, and you've had two years of med school. Given the limited ability to do procedures in the chopper, it doesn't make much difference. And I can radio in if something happens that concerns me."

"I wonder what happened?"

"One thing you'll learn in the Emergency Department is that you will likely never know much about what happened before or after you see a patient. Our job is assessment and then stabilization or treatment. After that, we admit or discharge them. Either way, what happens after they leave the ED is opaque in most cases. That was the most difficult thing for me to adapt to."

"Five minutes out," came over the headset.

I listened as the co-pilot spoke to the controllers, and, as predicted, just under five minutes later, the helicopter touched down on the helipad. As usual, the rotors continued to turn as the local staff rushed out, ducking, and the co-pilot opened the door.

I carefully jumped out, took off my helmet, and moved directly to the doctor, who had arrived with two nurses, an orderly, and a medical student. I put my ear near his mouth and my mouth near his ear so we could converse over the noise of the helicopter engines and blades.

"Jones, burn specialist," he said loudly.

"Loucks, trauma surgeon; John Doe; late twenties; 50% full-thickness burns to arms and torso; escharotomy; IV Ringers; dobutamine and vancomycin; ankle BP 110/80; pulse 100; PO₂ 94% on vent; minimal urine production."

I handed him a copy of the chart, he signed my form for our chart, and they moved the patient from the helicopter. As soon as the patient was clear, I got back into the helicopter, and the co-pilot shut the door. He climbed in, checked with the controller by radio, then announced our departure. I put on my helmet, and as was my usual practice, as soon as the helicopter left the ground, I leaned back and closed my eyes.

I wasn't sure how long I slept, but I was jolted awake when a klaxon sounded, and the helicopter shuddered. The nose of the helicopter dipped, and I felt my stomach move as it did on rollercoasters.

"Engine failure!" I heard over the headset. "Emergency landing! Hang on!"

"Oh, God!" Tom moaned in distress, though I barely heard him without the intercom button. "No!"

"We have two engines," Kellie said calmly. "They'll put us down on a road or other flat surface."

She was WAY too calm in my mind. Sure, I slept on the return flights, but this was different. I did the only thing I could — prayed the Jesus Prayer. About thirty seconds later, we made a rough landing, and the co-pilot ordered us out of the chopper. Tom needed no encouragement, throwing open the door and bolting out. I quickly followed him, but Kellie simply calmly exited the passenger compartment.

I immediately surveyed where we were and saw we'd landed on a baseball field — in the shallow outfield, just past second base. I turned and saw a bit of smoke coming from one of the two engine compartments, VERY happy the helicopter had two engines. The pilot and co-pilot both had extinguishers in hand but weren't using them.

Tom, still moving, stumbled and collapsed onto the ground. Kellie quickly moved to him. She checked his pulse, then had him lie down.

"180!" she announced.

My heart was racing, too, but probably around 130. Kellie, on the other hand, was cool as ice.

"Let's see if it resolves," I said. "Tom, just try to breathe normally."

"How are you, Doctor?" Kellie asked.

"Well, I managed to avoid soiling my underwear, so there's that."

After about a minute, Tom sat up and seemed to be doing better, with his pulse down to about 130. The pilot came over to us.

"I called it in. We're about six miles from the hospital. They'll send someone for you; we'll stay with the bird until the maintenance crew arrives."

"Will you fly it out?"

"No way. They'll put her on a flatbed and take her back to the barn."

About fifteen minutes later, a van arrived to take Tom, Kellie, and me back to the hospital. Kellie and I helped Tom into the van, we all buckled in, and the co-pilot closed the door of the van.

"Tom," I said when the van pulled away, "when we get back, take a thirty-minute break in the on-call room."

"Thanks," he said.

"Come see me after your rest period, and we'll evaluate."

"I will."

"How many mechanical failures did you experience, Kellie?" I asked.

"Four, but as with this, the pilot simply managed it and set the helicopter down on flat ground. We had one really hard landing, worse than the one we just had, and that helicopter was salvaged for parts because it wasn't worth fixing. The others were back in the air within a day or two."

When we arrived back at the hospital, the news had spread, and Ghost came to talk to me while we took off our gear.

"Tom is going to take a break," I said. "His pulse skyrocketed."

"How are you?"

"Fine. My pulse went up from the adrenaline hit, but it resolved quickly. Kellie, on the other hand, has ice water in her veins!"