Trauma Junkie: Memoirs of an Emergency Flight Nurse

First Chapter

Chapter 1

Lifting Off

I had the fear. The all-encompassing fear. That sickening, sinking feeling that the events unfurling before me were barreling rapidly out of my control. At any moment, the beeper would signal the end of this charade, this idea I might someday join the ranks of the best of the best, the elite of the nursing world. Flight nurses.

The helicopter was quiet for now. Morning preflight was done, and Harry had gone back into quarters to start the day's paperwork. The smell of Jet A fuel wafted through the hot July air. Our trauma bag was safely secured with the seat belt on the Day-Glo orange litter, and the tubing for the blood pressure monitor was coiled and stowed so it would be ready to use with one tug. The EKG patches, already attached to the cable, were set to be slapped onto our patient's chest. We were ready for anything. The only thing missing was some unfortunate soul who required our services. For a brief moment, I had a fantasy that maybe I could do this job after all.

Suddenly the pager vibrated on my belt. My stomach felt as if I were on the roller coaster from hell and my sweating hands shook as I grabbed the beeper, pushed buttons randomly and inadvertently deleted the message. My first act, and I had screwed it up.

My career as a flight nurse was off to an inauspicious start.

Harry, one of my mentors during training and my partner that first day, came loping out to the helicopter with Pete, our pilot, running close behind. "All right, let's go," he yelled as he swung into the front seat and effortlessly locked in with the four-point belt. "Ya all set?" he asked, reaching for the maps. "Harry, I'm not ready.I erased everything on my pager. I don't even know where we're going."

"Now, just relax and take a deep breath," Harry said as I panicked. "I'm right here, and I'll help you. We're going to Santa Cruz County on Skyline Boulevard for a motorcycle accident." Pete cranked up the two jet engines, drowning out any further conversation until the intercom was powered up.

As we lifted off I froze, entirely forgetting everything I had learned in our radio class. Despite a week devoted to learning the system we used in the helicopter, and the various county frequencies, it was all now a complete blank. The nurses had four different radios to manage and the pilot three--seven frequencies that might be blaring all at the same time.

I squinted down at the radio console's millions of small buttons and switches. Harry reached over and switched my station to the dispatch radio to let them know of our liftoff time and ETA to the scene. He smiled and patted my hand.

There is a specialized language used on the radios, and I certainly hadn't mastered it. I tentatively keyed up the mike to
our dispatch. "Uh, CALSTAR One, this is CALSTAR, uh, base. I mean, this is CALSTAR One. We, uh, just took off--uh, lifted off from Concord."

There was a slight pause as dispatch considered my garbled message, and I could hear snickering in the background. "CALSTAR One, we are the base. You are the helicopter. And you are responding to a motorcycle accident on Skyline Boulevard. Your map coordinates are Thomas Brothers, page 64, B4. Your ground contact will be Captain 61 on fire white, frequency 154.280. Do you have an ETA?"

I was unsuccessfully trying to write down all of this essential information when I realized I had no idea what our ETA might be. Keying up the transmit button instead of the intercom button, I said, "Pete, they want to know what our ETA is."

Dispatch responded wryly. "CALSTAR One, you hit transmit instead of intercom."

"Oh, sorry."

Pete was up front, giggling. "Janice, relax. It's going to be sixteen minutes if the coordinates I have are correct."

Now I had to do my arithmetic. Let's see. It was 11:12. In sixteen minutes it would be, well, uh ...

Harry again came to my rescue. "Base, CALSTAR One. We have an ETA of 11:28. Copy map coordinates and ground frequency. Confirm Valley Medical is open and willing to accept?"

"Open and accepting," base responded.

The first part of the flight hadn't gone well, but I was determined to get something right. As we approached the scene, I carefully dialed in our ground frequency and rehearsed the dialogue in my mind. I confidently switched off from the dispatch radio and onto the ground unit. "Captain 61, this is CALSTAR. We have an ETA of 11:28. Please let us know when you have a visual on us." Quite pleased with myself, I sat back and awaited their response.

"CALSTAR One, Captain 61. Your landing zone is going to be--"

Abruptly, his radio transmission was drowned out by traffic on two other concurrently running radios. One was a paramedic giving a lazy radio report to another hospital: "... and we have him on four liters of oxygen, and are giving an Allupent nebulizer..." This traffic competed with the comm radio, which was also blaring: "Cherokee 654 Bravo, turn into left downwind after departure. Traffic in the pattern is a Cessna at your two o'clock."

I reached over to switch off the distracting radios, and succeeding in turning them all off. Including our ground contact. Desperation set in. "Harry, help me. I just turned off all the radios back here," I pleaded.

He reached over and flipped up the correct switch. "You're doing fine," he lied. "Takes a while to learn to work the mighty Wurlitzer. Now all you need to do is get our landing zone instructions. Piece of cake."

Despite my ineptitude, I did manage to get our LZ information from the fire department, who were already on scene. We were to land in a field about one mile away from the actual incident, as there were no safe LZs nearby. A fire truck was waiting to transport us to the accident. Pete circled the area and gently settled us onto the ground. "You're cleared out," he said. As I scrambled out of the helicopter, I remembered to buckle my seat belt behind me so I could find it quickly when we returned with the patient. Harry grabbed the trauma bag and together we scrambled up into the cab of the fire truck.

"Hey," Harry greeted the firefighters. "How's it going?"

"It's pretty crazy up here," one replied. "We now have two separate accidents less than a mile apart. You guys are getting the MCA patient, who planted his face into the back of a parked van while he was going about seventy miles an hour. No helmet--he's pretty messy. The ambulance that was supposed to respond to this accident had to stop up the road for the other one. I don't know if a second ambulance can get to this one."

I was only vaguely listening to this conversation. The fire truck ride was a hoot, and I was grinning like an idiot as we bounced along the rutted road, reflecting on what an enormously cool job this was. As we turned onto Skyline, the firefighter switched on the lights and siren to get through the backed-up traffic. I saw a sign that indicated we were leaving Santa Cruz County and entering San Mateo.

Harry groaned. "So this incident is actually in San Mateo, huh?"

"Yup," the firefighter said. I vaguely wondered what difference that made. "Well, here we are."

Out the window, a group of firefighters huddled around a supine figure on a backboard. We climbed out of the huge truck and trotted over to our patient. "Oh, Jesus," I said softly. This poor man wasn't recognizable as human. His head was a jagged mass of bone and tissue; his entire face was disconnected from his skull. Facial fractures are graded on the LaForte scale from one to four, depending how much of the face is still connected. This guy had a LaForte fifteen. One of the firefighters was vainly attempting to assist his breathing manually with a bag and mask, but I could tell it wasn't working well. Every time he gave the patient a breath, air would spurt out through holes in his forehead.

Harry asked me to take over the bagging, and the firefighter stood up and handed me the mask. Feeling a little squeamish, I knelt down to resume the impossible task. Because of his extensive facial trauma, there was no way to get an adequate seal on his face to force air into his lungs. I tried to readjust the mask several times, but it simply wasn't working. To make matters worse, with each breath I gave him, fine spray of blood squirted out and covered my trauma goggles, making it difficult to see.

"You guys got any portable suction? His airway is filled with blood, and we have to clear it out if we're going to get this guy tubed."

Intubating a patient is often among the first things EMS does on a scene, since a patient who can't breathe adequately on his own is at risk of brain damage within minutes. We put a lighted instrument called a laryngoscope into the mouth, pulling the tongue and epiglottis out of the way to locate the vocal cords at the entrance to the trachea. Then we insert a polyvinyl endotracheal tube (ETT) with a balloon at the end. Once this balloon is inflated, it creates a seal that prevents air from leaking out when we force a breath in with the bag. It also stops the patient from inhaling stomach contents if he vomits, a common scenario with a full belly. It's a crying shame for someone to survive the trauma, only to die of aspiration pneumonia two weeks later.

One of the firefighters returned with the suction, and Harry crouched by me as I was bagging. "When I open his mouth, hold his neck still," he said. "With this kind of impact, he's for sure got some injury to his neck. We don't want to complete a c-spine fracture and make him a quad."

I nodded and moved over to the side, gently holding our patient's head in neutral alignment. Harry knelt down and placed the laryngoscope in what was left of his mouth, trying to suction out the blood and debris and get a view of the vocal cords. "It's no use," he announced. "I can't see anything. Let's just get going."

Obediently, I took over bagging again and looked around. Under normal circumstances, there would be an ambulance there to take us back to the helicopter. But the paramedics were at the other accident and there was no place on the fire truck to put the patient. I had no idea what we could possibly do. The firefighters had finished strapping our patient to the backboard and were ready to go. But how? Harry, of course, had the whole thing figured out.

"I'll be back in a sec," he said, and jogged over to a man in a small black Toyota pickup stopped in traffic. "Excuse me, sir, but would you mind giving us a ride to our helicopter? It's about a mile down the road, and we really need to get there." The driver, speechless, just nodded his head. "OK, you guys. Load him up over here," Harry yelled, pointing to the back of the man's truck. Together we lifted the backboard and six of us piled into the bed of the truck. The fire engine cranked up and, with lights and siren, began escorting us through the massive backup. The driver of the pickup stared at us through the rearview mirror with eyes the size of saucers. He was rooted to the spot, and made no effort to move.

"Drive!" Harry shouted through the rear window, gesturing down the road. "Just drive! Follow the fire truck." Our carjacked driver nodded vigorously, gunned the motor and shot out of the traffic, making all of us lose our balance and fall over. We lost our grasp on the backboard and our patient nearly slid off the open tailgate.

I'm gonna die, I thought. I'm gonna die before we get to the helicopter.

As we passed the sign to the county line, Harry pounded on the window of the cab. "Hey, could you pull over for a minute? I gotta do something." Our driver nodded and hit the brakes, causing us all to fall forward. Harry rummaged around in the trauma bag and pulled out the surgical kit, and before I could register, he had prepped the patient's neck and made an incision over the cricothyroid membrane. Air and blood rushed out, and Harry gently threaded in a trach tube. He grinned at me as he began to ventilate the patient with the first decent respirations since the accident.

"Neat trick, eh?" he said. "We're not authorized to do that in San Mateo, but we can in Santa Cruz. I had to wait till we
got over the county line."

Harry turned to the driver again. "OK, we can go on now. You want to take a right on that dirt road up there." As we got to the aircraft and loaded him up, I reached down and felt for a radial pulse. It was reassuringly strong and regular. He was finally getting the oxygen he so desperately needed. We lifted off and had him in the trauma center in ten minutes.

I was just glad it was over.

This entire saga had started two months earlier, in May 1987, while I was in a restaurant in Tiburon overlooking San Francisco Bay. A friend of mine, Dana, was hosting a Sunday brunch celebrating my recent marriage. Mark was a co-worker in the ICU at Seton Medical Center, and our first date was purely out of mercy. I couldn't find anyone to go with me on a double date, and out of desperation I called him and begged. He only grudgingly agreed to go. At the time I thought he was gay--after all he was a cute male nurse from Texas with a great tush and a mustache. In San Francisco in the eighties, that usually meant gay. I found out that night he wasn't--to my surprise and delight.

Now I was sitting outside on the deck, enjoying the brilliant sunshine and sipping margaritas. "So what's this new job you have?" I asked as Dana mulled over the menu. Dana was another fellow nurse at Seton, and she was well known for seeking unusual jobs. She had worked in the emergency room, ICU, as a cruise ship nurse, and now she had started a position at California Shock/Trauma Air Rescue (CALSTAR), a nonprofit helicopter air ambulance serving the Bay Area. It sounded intriguing.

"It's a new company in a relatively new industry," she explained, sipping her drink. "It's a dedicated EMS helicopter that responds to scenes, as well as doing a lot of interfacility flights--like getting people from a small hospital and taking them to the larger centers that can manage them. You know, stuff like cardiac, pediatrics, and trauma patients that find themselves at tiny rural hospitals. We're doing a lot of transports for Children's Oakland."

But the most fun, she said, was the scene work. They'd fly out to accidents, scrape up the patients and try to get them to qualified care in that first "golden hour," when they'd have the best chance for meaningful survival after traumatic injuries. "A helicopter can really cut down on transport times. Besides, we can get them to specialized centers, too, that may be on the other side of the Bay--for things like burn care, spinal cord injuries, pediatric trauma. You'd love it."

"Do you carry a pager around and come in when something happens?"

"Oh, no," she laughed. "We go to work and stay there for twenty-four-hour shifts. When we're activated, we're in the air within five minutes."

"So how many calls do you do per shift?"

"You might get none, or maybe five in a row. You never know. That's what makes it fun. Every day is something different, and most of the patients we transport are pretty sick, if not dead."

This really got me interested. Like Dana, I had already worked in ICU and ER, and I seemed to gravitate to the most desperately ill. The work was intellectually challenging and often required rapid interventions, with little time to get bored. I realize now those were the early symptoms of adrenaline addiction, a condition identified many years later and common in paramedics, firefighters, police and other pre-hospital personnel.

I sent in my resume and was invited for a formal interview. To my surprise, I was offered a job the following week and began the orientation in June--three mind-numbing weeks in a classroom and six weeks as a ride-along. Now I was finally ready to fly on my own. At least that's what they said. I wasn't so sure.

In those early weeks, while our new quarters were being built, CALSTAR was temporarily based out of the Sheraton Hotel in Concord, about twenty miles outside of Oakland. The crew was housed in two rooms, one for the pilot, and one for both
nurses--the former filled with charts and maps, the latter with medical equipment.

I remember the awkward conversation Mark and I had about how my new job would impact our lives. "You'll be working twenty-four-hour shifts, huh?" he asked. "Guess that means you'll be sleeping at work."

"Sure will be strange not sleeping with you at night," I replied. "I'm going to miss you."

"So, uh, just where do you sleep at night? Guys in one room, girls in the other, like at camp?"

"I think the nurses sleep in one room and pilots in the other." There was a pregnant pause. "Are you OK with that?"

I was distinctly uneasy about the whole thing myself, now that I was actually faced with the prospect of sharing a room with Harry. Spending the night with a man I barely knew was bad enough; being in a hotel made it worse. And I was still mulling over a strange conversation I had had that morning with one of the other senior flight nurses, JoAnn, when she found out my first flight shift was to be with Harry.

"So do you know about him yet?" she had asked.

"Know about what?"

She leaned her head back and laughed. "You'll find out soon enough," she said, and walked away.

That afternoon, after we had finished cleaning up from our flight to Skyline Boulevard, I took a deep breath as I walked into our makeshift quarters.

"Well, well, well," Harry said. "That wasn't so bad, was it?"

Actually, I was exhausted from the ordeal and I settled into a chair, stretching out to admire my new boots and sleek black flight suit. The company had given me a hand-me-down from another flight nurse who had recently left, and it was a size too small. It would be another month or two until I got my own custom-tailored Nomex flight suits. I didn't care. I was delighted just to be here.

Not long after, the phone rang. It was dispatch, activating us to another motorcycle accident, or MCA, this one involving a train on the eastern reaches of Contra Costa County. Nervously, I ran out to the helicopter with Harry jogging along at my side.

"Ya ready?" he asked as we climbed into our seats and belted in.

My heart was pounding, and I could barely buckle my seat belt. "Yeah, um, sure. Now where are we going?"

"Deer Valley Road. Out behind Mount Diablo."

As far as I was concerned, it might have been Outer Mongolia. Like Steinberg's old New Yorker cartoon that shows the world more or less ending at the Hudson River, my knowledge of the Bay Area stopped at the San Mateo Bridge. All of the East Bay was a major mystery to me, and I only had a vague idea of the location of Mount Diablo--it was that peak you could see from San Francisco on a clear day.

As we circled the scene, I could see a group of firefighters huddled on the ground around a body on a backboard, next to a set of railroad tracks. The train was stopped, and the mangled remnants of a motorcycle were jammed under the front engine. Several railroad employees and a couple of firefighters were pulling on the motorcycle in a futile attempt to clear it from the track. We landed about a hundred yards away to avoid dusting off the group with our rotor wash.

Harry jumped out of the helicopter with the trauma bag and trotted over to the patient. I glanced over at the paramedics, who were now doing CPR. That's not a good sign, I thought. Patients that arrest in the field have less than a one percent chance of survival.

By the time I was ready to go meet Harry after securing the helicopter, he was already on his way back with the patient and a couple of firefighters. I met them halfway, and as we trotted along, he gave me a brief version of what was happening.

"Twenty-four-year-old guy," he yelled over the noise of the rotors, "playing chicken with a train on his motorcycle. He's got a head injury, flail chest, and an amputated right leg. Initially he was breathing, but nothing now. The medics tried to get him intubated, but couldn't get it in. So we'll try and tube him in the helicopter en route. No sense in wasting any more time here."

I nodded, and helped the firefighters load the patient in the aircraft. After securing the back door, I did my last walkaround to check doors and cowlings. Then, as I was climbing in, I spotted a firefighter running toward the helicopter carrying a large plastic trash bag. Pete was already spooling up the engines in preparation for our departure. I held up a finger to signal Harry to wait a minute and ran back out. I briefly saw his expression of disapproval as I ran back--he was busy and needed help. I knew what he was thinking: his rookie partner had deserted him, prolonging our ground time, which we tried to keep to five minutes.

I ran down the hill toward the firefighter and he handed me the large plastic bag. "I think you'll need this," he yelled over the noise of the helicopter. I assumed he was handing me the patient's belongings. I nodded and ran back up the hill, where the high whine increased as Pete pushed the throttles forward, getting ready to lift off. As I was running, the bag, which probably weighed ten or fifteen pounds, was banging against my leg, and something sharp was poking me. Puzzled, I opened the bag and peered inside.

It was a leg. Neatly severed at mid-femur. With a tennis shoe on the foot. I was horrified, and held the bag far in front of me as I clumsily ran along.

As soon as I reached the helicopter door, I handed the bag to Harry and then jumped in, latched the door and belted in. I gave Pete the thumbs-up, indicating we were ready in the back. As soon as we cleared the landing zone, Harry, who was breathless from performing chest compressions and bagging by himself, keyed up the mike. "Where did you go?" he demanded, clearly perturbed. "We don't delay transport to collect patient belongings."

I had my hands full doing the chest compressions now, and I nodded towards the bag. "Well, it's not really belongings in the normal sense of the word," I yelled over the noise.

Harry reached over, opened the bag and peered in. "Jesus," he said. "You could have at least warned me."

I shrugged, and we got down to the business of getting the patient intubated and pushing drugs to try and bring him back. Of course, there wasn't much left to get back. By the laws of gross tonnage, it seemed pretty clear that a train would win over a motorcycle every time, making this patient's planning seem somewhat shortsighted. Darwin was right.

By ten o'clock that night, we had finished all our paperwork and, despite my efforts to delay it, bedtime had arrived. Grabbing the nightclothes I had carefully chosen the previous night, I dashed into the bathroom. I put on a leotard, leggings, a T-shirt and a scrub suit, covering it all with a very large, ugly, stained terrycloth robe. After twenty minutes of brushing my teeth and scrubbing my face, I faced myself in the mirror. "Now Janice," I told myself firmly, "you're being ridiculous. This is a professional organization, and we conduct ourselves as professionals. Harry is not a midnight rapist. Now just march your bad old self out there and get into bed." Cautiously, I opened the door and peered out.

My worst fears were realized. Harry was leaning over his duffel bag, wearing nothing but his saggy BVDs. I whipped back into the bathroom, slamming the door behind me. Leaning against the wall, breathing heavily, I considered my options: either run screaming into the night, effectively ending my career as a flight nurse, or just deal with it. Surely Harry wasn't going to sleep in his underwear with a woman he barely knew? I leaned my head against the wall until my breathing slowed to normal.

After a few minutes, I stuck my head out the door again. Thankfully, Harry was now sitting up in bed, wearing a T-shirt, casually reading. "There you are," he said. "I was beginning to get worried about you. Everything all right?" He was obviously unaware of my discomfort.

"Uh, yeah, just fine," I answered, sidling past him, avoiding eye contact and diving into my bed, still swaddled in three layers of clothing. "I was just flossing." I turned away from him and picked up my book. "Pretty busy today, don't you think? Did I do OK? Boy, oh, boy, what a day. I can't wait to go home tomorrow and tell Mark all about this." I realized I was babbling and pulled my book closer. A strained silence filled the room.

About fifteen minutes later, I rolled over to shut off the light. Harry looked at me, obviously uncomfortable. "Um, Janice. I think I should tell you something. It's only fair."

Uh-oh, here it was. He was going to divulge some deep secret, and I barely knew him. Or maybe he was going to admit to some sexual deviance, or God only knows what. "What do you need to tell me?"

"Well, I have this problem."

"What kind of problem?" I asked, becoming more alarmed by the second. I was poised to scoop up my handbag and flee.

"Well, a problem with, uh, gas. You know, flatulence. Some people find it kind of distressing."

Relief flooded over me. He was worried because he had a little gas now and then? Didn't we all? "Oh, Harry, don't worry about it. I thought you were going to tell me you were some sort of twisted pervert."

He laughed, the tension broken. "No, it's not as simple as that. I don't think you understand. This isn't like regular gas. It's kind of, well, major gas."

"Believe me, you don't need to worry about that."

"I just wanted to warn you, that's all."

So this was the reason for the mysterious warning from JoAnn. I figured it was probably an ongoing CALSTAR joke. "Good night, Harry." I carefully placed my beeper next to the phone and arranged my boots and flight suit so I could quickly scramble into my clothes if we got that midnight call. Harry chuckled at my earnest efforts.

"You are a newbie," he said, stuffing his beeper into his boots. "Aw, you'll figure it out soon enough." Shaking his head, Harry switched off the light.

I was determined only to doze, so I wouldn't sleep through an activation. Harry's breathing got slow and regular, then became a loud snore. "They didn't mention this," I thought to myself as I slowly settled into a deep sleep.

Suddenly the quiet was shattered by an explosion. I sat bolt upright trying to orient myself. Had a bomb gone off? Gunfire? Where was I? Where was Mark? Why was I in this strange bed? Then Harry's malady fully asserted itself. A foul cloud wafted over to my bed, causing me to sputter and cough. Harry, who had also been awakened by the sound, jumped straight up.

"We got a flight? Where are we going? Where are my boots?" He scanned the floor, searching wildly for his gear.

"Harry, calm down. We don't have a flight. You farted," I said, trying to hold my breath.

"My God, sure did," he replied, fluffing his bedcovers. "Boy, this is a bad one."

My eyes were watering, and I do believe the wallpaper was peeling. "Oh, Harry, please stop waving your sheets. You're only making it worse."

"Oops, sorry. Maybe I could open a window." He struggled out of bed and began pawing frantically through the heavy drapes to find an avenue for fresh air.

"Harry, the window doesn't open. We're on the ground floor of a hotel, remember? Just open the door and fan, OK? Jesus, you weren't kidding. I didn't thing human beings could create such a thing. It should be listed with Hazardous Materials."

After a while, the room aired out. My eyes had stopped watering, and we could both breathe again. "Harry, does this happen often?" I asked. "If this is an every-night occurrence, I might just take my chances in the pilots room."

"Must have been those refried beans I had after dinner," he admitted. "Sorry. As long as I stay away from them and broccoli, I'm usually fine."

I sighed, turned over, and went peacefully to sleep. This was going to be a hell of a ride.