The day had been a scorcher, with the thermometer registering over a hundred degrees at noon. At the CALSTAR base, I sat outside on the steps with Carrie and J.B., our pilot, enjoying the evening breeze. It had been a quiet shift so far, but we knew it didn’t bode well for a full night’s sleep. After the oppressively hot day, the evening would invite people outdoors all over the Bay Area, and tempers always seemed to flare with a heat wave, which usually meant business for CALSTAR. The “knife and gun club,” as we called them, usually got busy around 10:00 p.m., and that hour was rapidly approaching.
I always enjoyed working with Carrie. At first glance, she seems to be the epitome of innocence. She is rather petite with large blue eyes and soft, curly blonde hair, and she comes off as rather soft-spoken and shy. When CALSTAR first hired her, we had a quick powwow before she showed up on her first day, and we were told to behave ourselves around her: No cussin’, scratchin’, or breaking wind. We were to behave professionally no matter what, for fear of driving this gentle creature away. That day was a horror. It started with a flight as soon as Carrie walked in the door, followed by three more in succession, and she stood up to it gracefully and tried as hard as she could to keep up with the pace. At 11:30 p.m. we finally sat down to eat and, of course, the phone rang immediately. Carrie let out a barrage of expletives that would make a sailor blush. She was just one of the gang thereafter.
“Should we start The Fugitive?” Carrie asked.
“We’re sure to get a call right at the best part,” J.B. replied, standing up and stretching. “But I’ve been wanting to see it. Might as well put it on.” We trailed into quarters, and J.B. stuck the movie into the VCR. Carrie popped some microwave popcorn and we settled in.
Sure enough, just at the climax of the movie, the dispatch phone rang. At 11:45 p.m., that could only mean we were going for a helicopter ride. It was a scene call—we were to do a pickup of a shooting victim in Richmond and deliver him to John Muir Hospital.
Richmond is a ghetto north of Berkeley where poverty and violence are endemic. When CALSTAR first began flying into Richmond, we were faced with some hostility and danger, but over the years we developed a rapport with the Richmond Fire Department and were now just part of the scenery there. Many of the calls were the result of gang fights and drug deals gone awry, and violence was so commonplace that gang members were not considered initiated until they had had at least one ride with CALSTAR. Generally the victims had some sort of violent trauma—bullet wounds, stab wounds, and assaults—and some were repeat customers. Richmond calls were quick and exciting, but the appalling social ills eventually became depressing.
Dispatch advised us that we were to pick up a patient with a gunshot wound. The scene of the incident was not yet secure and we were to rendezvous with the ambulance at the helipad at Brookside, the local community hospital that didn’t have the capacity for managing a major trauma patient.
Our flight time to Richmond would be about ten minutes, and there would be a return flight of eight or nine minutes to John Muir with the patient. Over the years we have been able to make this whole run—from skids-up to a completed chart in the rack—in less than ninety minutes. With luck, we might be able to get back to the movie by a little after 1:00 a.m.
As we lifted off into the tropical night, I felt that old exhilaration of flying. I smiled as J.B. banked the helicopter off to the west toward Richmond. The chattering of the radios, swapping traffic on the emergency frequencies, the noise and smell of the jet engines, all seemed reassuringly familiar. “J.B., do you need the waypoints for Brookside?” I asked.
“No, I think the old girl could probably fly herself there without us.” Indeed, we had made this same flight dozens of times. The routine, as grisly as it could be, was familiar and reassuring. Carrie and I began preparing everything to receive the patient—turning on the cardiac, blood pressure and oxygen-saturation monitors, and spiking an IV with tubing and flushing the air out to get it ready for our patient’s arrival.
Our policy of landing at the Brookside helipad rather than at an unstable scene was the result of several unnerving situations. Since most of our calls to Richmond involved some sort of mayhem, there was nearly always quite a crowd around, and the police were not always successful in securing the landing zone. Whenever we landed on a scene we would invariably create a stir, and sometimes it almost turned into a riot. I remember pushing my way through an ugly-minded, uncontrolled crowd one night and being really frightened. It was also dangerous for the people in the crowd if they got too close to the helicopter rotors.
Then there was the possibility that the guy with the gun was still in the crowd, and not keen on our ministrations to his intended victim. He might try to finish the job, either when we were on the ground or in the air. EMS folks get shot at fairly regularly, in fact, and although I don’t know if a helicopter has ever been hit, it wasn’t unreasonable. A helicopter can be shot out of the sky pretty easily, simply by hitting the tail rotor.
As we circled the Brookside helipad, I looked down and saw two fire engines and a police car. A group of men stood around drinking coffee. “You’re cleared out,” said J.B. as soon as the skids settled.
Grabbing the trauma bag, I headed off for the group. They were all talking and joking. They seemed relaxed, so I assumed our patient was not badly injured. I greeted the fire captain with a wave and a smile.
“How are you guys tonight?” he asked, taking a sip from his Styrofoam cup. “Hope we didn’t interrupt anything.”
“We were just at the best part of The Fugitive, but I guess that can wait. What have you dredged up for us?”
“Aw, just some guy who got shot,” he said, shrugging.
“So I take it he’s not too bad?”
“Actually, he’s pretty much dead.”
I didn’t have time for more questions, as the ambulance was approaching with its lights flashing. As it pulled up in front of me, I saw a small rivulet of blood dripping out of the back doors. “This doesn’t look good,” I thought as I opened the door. A man was lying on the gurney, unresponsive, with blood gushing onto the floor of the ambulance from a gaping hole in his head. Along with the flow of blood, chunks of bone and brain tissue oozed off the backboard. One of the ambulance paramedics was at the head of the gurney trying to bag the patient, and it didn’t appear to be going well. The second paramedic was trying to get an IV started. I glanced behind me. The firefighters and cops continued their lively discussion, ignoring the ambulance’s arrival.
The first paramedic, Liz, whom I had met before, looked up and started telling me the story. “This is a twenty-year-old male with two gunshot wounds to the head—large-caliber gun at close range. He was initially hyperventilating and posturing, but is now somnolent with fixed and dilated pupils. There was a 500 cc blood loss on scene, and as you see it’s still bleeding briskly. There was a lot of brain tissue on the ground where we found him. We’re seeing agonal respirations, but have been unable to get him intubated.” Agonal respirations look like a fish gasping for air—irregular, slow and ominous. They’re a primitive reflex from deep within the brainstem and an indication that death is imminent.
As Liz was giving her report, I crawled up past the second paramedic to get to the head of the bed. My boots slipped in the pool of blood, and I nearly landed on my hip in the gruesome lake. As I got to the front of the gurney, I breathed a little sigh of relief—the wounds were all in the cranium, and the young man’s facial structures appeared to be intact. I reached over and palpated his face and nose, which were stable. His eyes were partially open, with fixed and dilated pupils. The eyes were covered with a blue-tinged haze, indicating that he had, not surprisingly, lost his blink reflex. I pushed on his jaw, but it was clenched. This meant we had two options for securing his airway so we could get oxygen into him. One was to put in a nasotracheal tube, but this is a blind technique and there’s always the possibility of “tubing the goose”—that is, putting the tube down his esophagus instead of his trachea. The other option was to intubate him orally, but since his jaw was clenched, we would have to do a rapid sequence induction (RSI) and paralyze him first. He didn’t yet have an IV established to give him the necessary drugs, so we would have spent more time on the ground trying to do that. And clearly this man wasn’t going to get any better lying in an ambulance.
I considered the options. If the paramedics had already had trouble getting the tube in, he probably didn’t have an easy airway. In addition, after multiple intubation attempts, the airway was probably pretty beat up and bloody, making my subsequent efforts more difficult. I thought a nasotracheal tube might work out better and, if I couldn’t get it in, we would do an RSI in the helicopter en route to John Muir.
Carrie arrived at the back of the ambulance and stood for a minute surveying the carnage. “What a mess,” she commented as she climbed into the back.
I gave her a brief report, relaying my plan for a nasal tube. She nodded as she helped me set up my equipment. “Facial bones intact?” she asked. “Don’t want this tube to head north and end up in his midbrain.”
“Yeah, looks like most of the trauma is in the cranium itself. He’s got only agonal respirations, but at least he’s breathing enough to help guide the tube in.” I squirted Neo Synephrine up our patient’s nose, pulled out a 7.5 endotracheal tube and covered it in numbing lidocaine jelly. Gently I inserted it into his nose. “Please go in, please go in,” I muttered as I passed it through the nasal turbinates and watched for a mist as he exhaled. With each breath, I gently advanced it further until he coughed slightly, and a little blood squirted out of the end of the tube. We were in. I inflated the balloon and murmured a quiet prayer of thanks to the intubation gods. Carrie handed me an ETCO2 monitor, which confirmed that we were in the right spot. Liz whipped out a stethoscope and listened to the chest for breath sounds as I bagged.
As Liz handed me the tape to secure the tube, the second medic hit a vein and got the IV hooked up and secured. While Carrie and the medics quickly finished packaging the patient—that is, immobilizing him on the backboard—I was able to suction out our patient’s airway. We were set to go.
During all of this, I was vaguely aware of loud laughter outside the ambulance. The group of firefighters and cops had grown, and there were now about fifteen people milling around outside cracking jokes. Liz stuck her head out of the ambulance and asked for four people to load the gurney onto the helicopter. No one heard her, and they continued to talk loudly. She became exasperated.
“Do you guys think you can break away from your fun for a minute and help us get the goddamn patient loaded?” she yelled over the noise.
Several of the firefighters turned, looking surprised, and a couple of them grabbed the end of the gurney as we slid it out of the ambulance. The rest of the group turned back to their discussion.
“Carrie,” I said, “take over the airway while I go get the aircraft set up, OK?” She nodded, and took over bagging. I clambered out of the back of the ambulance and walked down to the helipad. I threw the trauma bag over the seat of the helicopter and turned on the monitors, expecting the crew to be there to load the patient. Instead, they were still at the back of the ambulance. Liz appeared to be yelling at one of the cops, and she was shaking her fist in his face. He had his hands on his hips and was yelling back at her. “What the hell?” I wondered aloud.
At that point, Carrie gently took Liz’s shoulder, and pulled her away from the cop, at the same time pushing the patient toward the helicopter. I could see Liz get in one last shot at the cop as they wheeled the gurney down to the heliport ramp. Together we loaded our unfortunate patient into the helicopter and in a moment lifted off into the night. I glanced at my watch. We had been on the ground for twelve minutes.
As soon as we were airborne, we started hooking our patient up to the monitors. His initial blood pressure was 240/160, coupled with a heart rate of 160. I sat back for a minute, trying to figure out what might be happening with this man. High blood pressure with a head injury pointed to a clinical syndrome known as herniation. After a head injury, the brain swells, just like an ankle after it’s sprained. Since the brain is enclosed in a bony compartment that does not expand with the swelling, the pressure keeps increasing. The tissue literally gets squeezed out through the only outlet available, the foramen magnum, which is the hole at the base of the skull where the spinal cord emerges. As one would imagine, this is not a good thing. Herniation is usually accompanied by a slow heart rate and an irregular breathing pattern. The usual intervention is to drill several holes in the skull, known as burr holes, to try and relieve some of the pressure. In this case, however, it didn’t add up. The patient’s heart rate was too high, and he already had two huge holes in his cranium from the gunshot wound, which continued to ooze blood and gray matter. And he still had only agonal respirations.
No, this didn’t make sense. Maybe it was a problem with the monitors, or maybe the vibration of the helicopter had caused the abnormal reading. I reached over and took another blood pressure. This was much more what I expected—80/30, which reflected the enormous blood loss he had suffered. Carrie looked at the monitor, nodded, and started pushing the fluids to replace what he had lost. With the bag, I hyperventilated our patient to blow off the CO2 he had undoubtedly accumulated before being intubated. This maneuver also helped to decrease the brain swelling by constricting the blood vessels between the brain and the skull.
All of this activity was futile. With this injury, the patient had no hope of meaningful survival, even though his heart was still beating. This man was going to die; the only question was when. The best we could hope for was stabilization until he could be evaluated for organ donation. Patients with gunshot wounds to the head are perfect organ donors. Generally they are young men in perfect health with a single exception: They no longer have a functional brain.
As we arrived in the trauma room at John Muir, we moved the patient off the helicopter’s backboard onto the hospital’s gurney. A large chunk of gray matter slid off our litter and splattered onto the floor. The trauma surgeon regarded this impassively and returned to his evaluation.
A quiet descended over the room as the team started their workup. None of the usual frantic activity of a trauma room was apparent; everyone knew what the outcome of this case would be. In the bright lights of the room, I now saw the telltale track marks in the man’s veins, indicating IV drug use. That meant he would probably be a lousy candidate for organ harvest.
Carrie and I gathered up our equipment and headed for the workroom to start the distasteful task of paperwork. As soon as we were out of earshot of the staff, I turned to Carrie. “What was going on back there at the helipad? It looked like Liz and that cop were about to get into a fistfight.”
Carrie stretched and yawned. “She got upset because of their attitudes. She thought she was trying to save somebody’s life, and they were all acting like they were at the beach. I guess she took it personally.”
I understood Liz’s hostility. She was trying to do her job, which in this case was saving another human being’s life, and she felt the cops’ behavior didn’t reflect the gravity of the situation. But I could see the cops’ side, too. They saw this carnage first-hand—beatings, shootings, stabbings, drug overdoses. While we at CALSTAR usually only saw the ones that were alive, if only barely, they witnessed man’s inhumanity to man over and over, day after day. In order to cope with this brutality, they learned to build a thick insulating shell around themselves. Even the most macho of men must go home and cry alone in a closet after they’ve seen a murdered toddler or heard a burn victim screaming in agony. Building an enormous emotional bunker is the only way they can survive.
Our patient died later that night. He was found to be HIV-positive, decisively precluding him from organ donation. The shooting turned out to be over a quarter gram of crack. This man was someone’s son, brother, husband, friend. And yet I found myself surprisingly unmoved. I simply found the whole incident a stupid waste of a life. I guess I’ve built a bit of an emotional bunker myself.
One of the things we have to do as caregivers, ironically, is learn to care for ourselves. That’s often difficult—after a time, nurses don’t recognize their own needs, even immediate ones. There are times, however, when we have to withdraw from the work after a particularly painful call.
The first time this happened to me I never opened my trauma bag. There was no gore, no haunting screams—there wasn’t even a body. And yet it was one of the worst calls I ever went on.
It was a warm summer afternoon, and CALSTAR was activated to Lake Del Valle, above the Livermore Valley. The dispatcher informed us we were going after a “drowning victim, UTL,” or unable to locate. None of us was terribly concerned. With many UTL calls, the victim has merely wandered off to the snack bar or is taking a nap somewhere. We usually got canceled before we even reached the scene.
With Carl at the controls, we flew toward Del Valle, getting the details of the incident over the radio. A middle-aged couple had taken their small fishing boat out on the lake. While they were twenty yards off shore in fifteen feet of water, the husband had fallen overboard and not come back up. The wife had jumped in the water to try and grab him, then was unable to climb back into the boat. Ranger units spotted her and pulled her and the boat back to shore. The husband had still not been found. Several bystanders and rangers were now in the water trying to locate him.
This changed the story completely. If we knew there were witnesses, this was probably a real drowning after all. The clinical implications changed as well. The man was thought to have gone down forty-five minutes ago. If that was true, it would be difficult to get anything back if they could find him. Patients pulled from the water often get full-court-press resuscitation, as the cold may help to preserve cardiac and neurological function. Only problem was, those magnificent saves were usually in water that was hovering around freezing. Lake Del Valle’s temperature was probably sixty-five to seventy degrees, making the preserving hypothermia a moot point at best.
As we approached the lake, Carl got instructions to land on a nearby lawn, in hopes the body would be recovered soon after we touched down. On the ground, we could see a large group of people huddled on the beach watching the rescue efforts. There were about six people in the water around an anchored Zodiac ranger skiff. This was not a high-tech rescue effort. The dive team had been mustered, but would not be there for some time. Meanwhile, the rangers and several bystanders were merely holding their breath, diving down and feeling around in the murky water, then popping back up to the surface, gulping air. Although this was not very efficient, there was no other alternative until the dive team arrived. Time was running out.
Nancy, who was flying primary, grabbed the bag and headed over to the incident commander’s group. They were preparing to launch another small boat and they wanted Nancy to go with them so she could begin rendering care as soon as they pulled the victim out of the water. I stayed back to provide security until Carl could shut down the helicopter. The rangers had cordoned off the beach, and a large crowd had gathered to watch. Occasionally a child would cry, but otherwise a relative hush lay over the scene as the high whine of the helicopter died out.
A woman stood alone on the beach, intently watching every move of the activity, oblivious of the silent crowd behind her. I knew this must be the wife. Part of me shrank back—after all, what is there to say when you are watching a team drag the bottom of a lake for your husband’s body?
Tentatively I approached her and placed my hand on her shoulder. “Hi,” I said. “I’m Janice, one of the helicopter nurses. Can I get you anything?”
She turned away from the lake for just a second and looked at me through teary eyes. “No,” she said tersely. “God damn it, they’re looking in the wrong place.”
“Where should they be looking?” I asked.
“Over to the left,” she said dully. “They need to be over to the left. I told them that, but nobody would listen.”
“I’ll relay that to them,” I said, reaching for my portable radio. “Nancy, this is Janice. I’m with his wife. She says you people need to be over to the left by about ten feet or so. You’re looking in the wrong place.”
“Copy that,” she replied from the boat. “Will advise.” There was a pause while Nancy relayed the message to the dive team. “They’re having a hard time because the water is so murky down there. The divers have exhausted the area to our left, and think the current may have moved him down to where they’re looking now.”
I turned back to the woman. “They think the current might have washed him farther south. That’s why they’re looking there. They couldn’t find him farther up to the left, OK?” She nodded, and continued to stare. “What is your name?”
“Jenny,” she said. I noticed for the first time she was soaking wet and shivering violently. The afternoon breeze was freshening, and she was wearing the same clothes as when she had jumped into the lake. Gently, I touched her shoulder.
“Jenny, listen. You’re shivering. Do you have any dry clothes we can get you into? We need to get you dried off.”
She roughly brushed my hand off her shoulder. “Will you leave me alone?” she shouted. “Can’t you see that wet clothes don’t mean anything? I don’t care. Now leave me alone.” She turned away from me, tears flowing down her cheeks.
She was right. At that moment in her life, the only thing that mattered were those people out there trying to pull her husband out of the water. Everything else was incidental, unimportant. I realized I had been using the wrong approach. I walked over to the lawn and grabbed a beach chair, then found a blanket. Carrying them back to the beach, I spoke to her quietly. “Jenny, here, why don’t you at least sit down and put this blanket around you. You’re going to get sick being in the wind like this.”
She glared at me for a moment, then obediently sat down. I tucked the blanket around her, and sat down next to her, staying quiet. She continued to watch intently, crying quietly. The minutes ticked by. About ten minutes later, I tried again.
“Jenny, can you tell me what happened?” I asked.
She didn’t take her eyes off the water. “Me and my husband George were out there fishing. He started complaining of pressure in his chest, so we decided we better get in and go for help. But the engine quit. He was standing at the back of the boat, trying to crank the engine, even though I told him I’d do it. Then I saw him kind of just sink to his knees, and then go headfirst overboard. I tried to grab him but he was too heavy and he slipped out of my hands. He just sank, like he wasn’t even trying to swim. He wasn’t even trying. I lost my grip, and he just sank away from me. Oh, God, if I could have only hung onto him. I jumped into the water after him, but he was gone. Then I couldn’t get back into the boat. If I could have only hung onto him, he’d be OK. It’s all my fault.” She collapsed into great heaving sobs. “It’s all my fault,” she repeated, choking.
I put my arms around her. “Jenny, you couldn’t possibly have pulled him back into the boat. He was too heavy. You did everything you could. You actually did everything right. If you hadn’t gone for help right away, all these people wouldn’t be looking for him. Believe me, this is not your fault.”
After listening to her story, it sounded like George had probably had a heart attack and then a cardiac arrest before falling into the water, making a resuscitation now even more unlikely. I wasn’t about to share this information with her. I sat there and rocked her as she continued to cry.
By now the dive team had arrived and was in the water, feeling their way across the muddy bottom with their hands. The rangers continued to dive, feel around, surface for air, then go down again. It was clear that everyone was running out of hope. The sun was getting ready to set, and the temperature dropped another ten degrees. Jenny was starting to shiver again.
“Jenny, listen. Give me your car keys, and I’ll go to your car and get you some dry clothes. You can stay right here and watch. I’ll bring them back to you, OK? You’re not doing yourself any favors sitting in these damp clothes.”
She nodded and rummaged through her purse. “Oh shit,” she said. “George has the car keys in his pocket. I can’t even get into the car. What am I supposed to do now?”
She wasn’t thinking this far ahead, but sooner or later she would need to get home. And she could use family or friends there for support. I could call them and have them come up and meet us here with a change of clothes and extra keys to the car. In the meantime, she really needed some dry clothes. I had no extras, but maybe someone in the crowd did. “Stay here, Jenny,” I said. “I’ll be right back.”
Walking to the edge of the beach where the crowd still watched silently, I called out, “Does anybody have any extra dry clothes? This lady is soaking wet, and we need to get her dried off. I need a sweatshirt and pants if anybody has any.” Almost every person started rummaging through their bags. A Hispanic man approached me, clutching a sweatsuit and a blanket.
“Will this help?” he asked in broken English. “It’s all I have.”
“Thanks,” I said. “Write down your address and I’ll try to have these returned to you, OK?”
He waved me off. “Don’t worry about it,” he said, “it is not worth it.”
“Thanks so much,” I said, and ran back down to the beach. Jenny had not moved.
“Jenny,” I said gently, “we got some dry clothes for you. Why don’t we go over to the restroom and get you changed. We should probably call somebody to come over with another set of car keys to get you home, too, OK?”
She looked back at the lake, then at me. “OK,” she said, slowly getting out of the chair. We walked slowly toward the restroom. Occasionally she would pause, turn back, and watch the lake. Then she stopped and turned to me with a steady stare. “He’s dead, isn’t he?” she asked quietly.
For a moment, I wasn’t sure what to say. I didn’t want to take away her last shred of hope. But I couldn’t lie. “Yes, Jenny, I think he is,” I said softly.
“I knew that. I just needed to hear it.” She started walking quickly for the bathroom, where I helped her change clothes. We didn’t speak. I then led her outside to the pay phone and handed her some change. I asked if she wanted me to stay while she called her family, but she shook her head.
“I need to call our son. I’d like to do this alone.”
“Whatever you wish,” I said. “I’ll be right over here if you want me.”
We waited and watched at the water’s edge for another hour, but the divers were unable to locate the body. Night was rapidly approaching, and Carl was overdue to go home. As much as we didn’t want to admit it, there was no point in our participation any longer. If they did find the man, he couldn’t be anything but dead by this time. We needed to get back in service and do a crew change. Despite this, I couldn’t leave Jenny by herself. Not, at least, until her son showed up. I thought about how she must feel, how I would feel if, by some horrible chance, that was Mark in the cool murky water. George was gone and Jenny, in a sense, became our patient.
Jenny’s son showed up a half-hour later. As soon as she saw him, she collapsed into his arms, sobbing. We packed up our gear, forgotten, and prepared to head home. I watched them for a moment, then gently touched her shoulder. “Jenny, we have to go now. You’ll be OK. I want you to remember you did everything you could. There was nothing you could do to change this, OK?”