We have a million-dollar helicopter. Four of them, in fact. The medical equipment onboard is state-of-the-art, and CALSTAR is constantly updating the skills and expertise of its flight nurses and pilots. We participate in a network of countless EMS people, from dispatchers to fire departments, law enforcement, medics and trauma centers, and we are all highly motivated to provide the best care that is humanly possible. But sometimes there are elements in a rescue that we can’t control, and people still die. Sometimes those people are children.
I gripped the steering wheel of the old diesel Mercedes as I rolled along the lower deck of the Bay Bridge on my way to work on a Saturday. The speed limit was fifty, but even at thirty-five miles per hour, I was still being buffeted by the high winds. Truck traffic had been banned from the bridge, and most people had sensibly stayed home. The radio was reporting gusts of up to forty miles per hour. It was going to be pretty bouncy in the helicopter today, I thought to myself. I made a mental note to make sure my seatbelt was cinched way down when we went on a flight, and I secretly hoped we wouldn’t have to go anywhere until things settled down.
It wasn’t to be. Late that afternoon, with Carrie and I were activated on a scene call to the far eastern reaches of Contra Costa County. The wind hadn’t settled down, and if anything, was worse. “It will get a little better when we’re past the ridge line into the valley,” said Carl, our pilot that day. “Let me know if either of you feel airsick.”
I shook my head at his sarcasm and radioed to dispatch. “CALSTAR base, CALSTAR One. We have lifted off at 16:36 en route to Discovery Bay. We have an ETA of fourteen minutes, getting us there at 16:50. Awaiting ground contact and frequency.”
“CALSTAR One, you are going to an MVA, auto versus truck, on Highway 4 near Discovery Bay. Your ground contact will be Highway 4 IC, and will be on Tactical Channel 5, 46.10. Be advised you will be transporting a pediatric patient.”
“CALSTAR One. Please check Children’s Oakland availability. Switching to Tac 5 now. We’ll be monitoring this frequency when you have further.”
I switched the radio to the ground frequency, looking up past Carl to see where we were to get an updated ETA. We were just coming over the ridge line and the radio signal would be line-of-sight to the scene. As we flew over the hills, we were buffeted by a particularly strong gust that lifted me off my seat. I cinched down my seatbelt, and got on the mike. “Highway 4 IC, CALSTAR One. We are currently over Kirker Pass, and have an updated ETA of seven minutes, getting us there at 16:48. Understand we will be transporting a pediatric patient and are currently checking Children’s availability. Please let us know when you have a visual on us and we will get landing zone instructions at that time. Further, could you please give us an age and approximate weight of our patient?”
“CALSTAR One, the patient is approximately six months old and is about seven kilograms. Will advise when we have a visual on you.”
“Oh, great,” Carrie groaned. “I hate doing the little ones.” She pulled out her brain book and started her drug and fluid calculations. “Janice, they said seven kilograms, right?”
“That’s what I heard,” I said, and started spiking a small IV with microdrip tubing, instead of the usual large-bore trauma tubing. We were all quiet as we approached the scene, straining to see the big fire trucks on the side of Highway 4.
Carrie spotted them first. “Carl, they’re at our one o’clock. On the right side of the road. You have them?”
Carl scanned the ground until he found the scene. “All right, got them.” He switched his radio to the ground frequency. “Highway 4 IC, this is CALSTAR. We have a visual on you. We’ll be overhead in less than one minute. Where would you like us?”
I peered down at the scene as Carl spoke with the incident commander. A big rig was jackknifed across the two-lane highway. In the ditch, a small white car laid on its left side. Its right side had been smashed, and the roof of the car had been sheared off by the fire department while extricating the passengers. Clearly anyone who had been in that car had some pretty heavy physics going against them.
“CALSTAR One, you’re landing zone will be in the small asphalt parking lot just to the west of us. Be advised we have some pretty strong winds down here, gusting to forty miles an hour out of the southeast.”
“Copy that,” Carl replied as he initiated an orbit over the scene to check things out. “There are wires on three sides of the approach we have to use because of the wind,” he relayed to us over the intercom. “We’ll have to take a direct approach over the scene, so let them know to batten down as we fly overhead. Other than the wires, I don’t see any other obstructions. If you are ready we’ll be turning short final.” Carrie and I confirmed we were prepared to land.
I radioed down to the incident commander. “Highway 4 IC, CALSTAR One. Be aware our approach due to winds and obstructions will bring us directly over the scene at low altitude. Please advise the crew to protect themselves from flying debris. We are on short final.”
“We are ready for you,” he responded.
The dispatch radio came up, asking for an update on our ETA. “Base, CALSTAR One, we are on short final, landing in less than one minute. Is Children’s available?”
“Children’s is available and willing to accept.”
“You can show us landing at 16:48.” We intently scanned the ground as we flew over the scene, watching for any problems. The ground crew draped themselves over a patient on a backboard as we flew overhead at less than a hundred feet.
Once on the ground, I handed the trauma bags to Carrie, who was directed to a nearby ambulance. I made sure no one was about to walk into our tail rotor and then pulled out the litter and prepared the straps for our baby. It was too windy to open the Thermadrape, or warming blanket, so I tucked it under the thin mattress on the litter and then trotted toward the ambulance. Outside the LZ, I was greeted by the firefighter who was assigned the task of aircraft security.
“Pretty windy up there today?” he asked as we walked together to the ambulance.
“I’ve seen worse, but you can bet I’m staying in belts today.” He grinned as I opened the back door of the ambulance. Carrie was kneeling on the floor finishing her primary assessment on a tiny infant who was lying on the gurney. One of the paramedics was bagging the little girl, and even from this vantage point I could see she was pale and cyanotic. On the other bench seat, a man strapped onto a backboard was yelling at the medics, with occasional pauses to cry. The smell of alcohol coming from him was overwhelming.
Carrie looked at me, obviously deeply concerned. “Janice, we have to get this kid out of here,” she yelled over the man’s ranting. “She was in a car seat, but in the front, and on the side they were hit. There was about four feet of intrusion into the passenger space. She’s unresponsive, and her respirations are really shallow. I’d like to intubate her here, but she’s got a clenched jaw and they haven’t found any IV access. So the plan is to start an IV en route and do a rapid sequence intubation in the aircraft. If we can’t find an IV easily, we’ll get an intraosseous line and go from there.”
I nodded and crawled up between them to put a tourniquet on the baby’s arm and to try to get a vein to distend while we were loading her. She was already packaged, and we gently pulled her out of the ambulance while her father continued to shriek.
The baby was so small that the medic and I were able to carry her ourselves, and we loaded her into the helicopter. I locked the litter, then escorted the medic outside the rotors. Carl was already spooling up the engines for liftoff. As I climbed over the seat belt again, I could already see this was going to be one of those pediatric flights from hell. As I tugged the seat belt tight, I gave Carl the thumbs-up, indicating we were ready in the back. Carrie finished placing the monitors as we lifted off and then returned to bagging our little patient and push the button to get the first blood pressure. I turned us on to hot mike, so we could talk hands-free during the twenty-minute flight to Oakland.
“Janice, get out the intubation kit and get me a 3.5 and 4.0 ETT with a stylet. Then see if we have any IV access.” As she spoke, I turned on the suction and placed the tip under the baby’s head in case she started to vomit. Then I pulled out the intubation kit, got out of the appropriately sized tubes, inserted a stylet, and placed it on the baby’s chest. I placed the right laryngoscope blade and handle to the left of her head. With that done, I took hold of the arm with the tourniquet and prayed for a thick vein to make itself known. Babies are always covered with a pad of fatty tissue, making IV access difficult enough, and when they are shocky it can be impossible. Often the only way we can give drugs, fluids and blood is by placing an intraosseous line, or a large needle we grind through a bone to reach the highly vascular bone marrow. While it’s a relatively easy procedure, the needle can easily fracture the small and delicate bones of an infant. Much to my relief, I saw a huge blue vein on the back of her hand.
“I’ve got a vein here,” I said to Carrie, reaching for an IV catheter. I swabbed the area with alcohol and looked up to see where we were. Unfortunately, we were about to start across the ridge line, which would make our already rocky ride more exciting.
“Carl, I’m about to start an IV back here. Could you try to keep it steady for a minute?”
“I’ll try my best,” he answered, “but it’s going to be bumpy.”
With the needle in my hand I concentrated on what now appeared to be a tiny vein. I grasped her hand and gently pushed the needle through the skin. Just at that moment, the aircraft lurched violently to the side. I hung on and waited until we straightened out, then advanced the needle carefully until I saw a reassuring backflash of blood in the needle. It threaded easily into the vein and as I connected the tubing I saw we had a great blood return. “Got a line,” I said as I taped down and reached for the medication bag to get the emergency intubation drugs.
I glanced at the monitors. Her oxygen saturation was in the eighties—way too low—and her heart rate was now ominously in the sixties, indicating she was about to arrest. Children, especially babies, generally have healthy hearts. Usually the reason for a slowing heart rate and imminent arrest is inadequate oxygenation, rather than damaged heart muscle, as is frequently found in adults. The fact that her heart rate was dropping meant she was at the end of any cardiac reserve. The first step to improve her perfusion was getting her intubated so we could get some oxygen on board and blow off the accumulating CO2.
Babies are also dependent on a relatively rapid heart rate to sustain their cardiac output. If the heart rate drops, the blood pressure plummets because they can’t shunt more blood from the periphery to increase the stroke volume, or the amount of blood pumped out with each beat. In adults, this shunting of blood to essential organs like the brain and heart is a primary way the body compensates for shock, which accounts for their gray, diaphoretic skin. But babies have immature nervous systems and they are unable to redirect blood to the preferred organs, so if the heart rate drops, everything gets bad very quickly.
“Give her atropine first,” Carrie said. “We’re about to lose her heart rate. Then give the intubation drugs.” She stopped bagging for a minute to check the light on the laryngoscope blade. “OK, I’m ready to go.”
I carefully drew up the appropriate drugs and administered them while I placed pressure on the cricoid membrane to try and prevent vomiting. Any vomit could end up in her lungs, potentially causing a life-threatening pneumonia down the line. Carrie checked the baby’s jaw thirty seconds later. “She’s paralyzed,” she said, and gently inserted the laryngoscope into our tiny patient’s mouth. Just at that moment, I could see an expanding pool of formula erupt, despite my cricoid pressure. “Shit,” Carrie muttered, and quickly grabbed the suction. She cleared the baby’s mouth and again inserted the blade. “I got the cords,” she said, and held out her hand for the endotracheal tube. The helicopter lurched again, and she lost sight of the tiny vocal cords hidden behind the tongue and epiglottis. “Damn, they were right there.”
Carrie resumed bagging to bring up the oxygen saturation. She loosened her seatbelt, flipped up the seat, and sat cross-legged on the floor of the helicopter, then retightened the belt. “OK, let’s try again.” Gently, she opened our baby’s mouth and inserted the blade once more. And again, just as she found the vocal cords the aircraft veered violently and she lost sight of them. We repeated this exercise several more times until it became clear this wasn’t going to happen until we were back on the ground. We were now over the Oakland Hills and would be landing in several minutes.
Our baby was starting to have a distended stomach after being bagged for so long. We slipped a tube into the stomach to release the air and, we hoped, suction any formula that may still be lurking down there. It helped a bit, and she was a little easier to bag. Just then we landed on the helipad with the bounce.
As we landed, all of us breathed a sigh of relief. Carrie handed me the laryngoscope blade and climbed out to stand on the skid. “You try it,” she said. The aircraft had to run for another two minutes to cool the engines before shutting down. Carrie reached over and held cricoid pressure as I inserted the blade into our patient’s mouth. To my relief, the cords were just under the epiglottis, and I was able to slip the endotracheal tube in easily.
“Got it,” I said as I started to bag, and I gripped the small tube tightly. Carl shut down the engines and ran to our side of the helicopter, where Carrie was checking breath sounds. “What can I do?” Carl asked as Carrie nodded her head to me, indicating she heard breath sounds on both sides.
“Grab the white tape to secure this sucker,” I said. Carl reached around and, instead of grabbing the one-inch tape to secure the tube, he snatched the two-inch silk tape and pulled off two feet of the stuff. Normally we use the two-inch tape to secure the head to a backboard, or stick a piece onto our leg and write on it like a portable clipboard. The tape was way too big to secure the tiny tube, and in any case, we only needed three inches. Carl held up the long expanse of tape while Carrie and I looked at him curiously.
“Um, Carl, that’s really good, but were not trying to mummify her,” Carrie said. “We need the smaller stuff.”
Carl realized his error, and hastily pulled the one-inch tape out, handing it to Carrie, who secured the tube to our baby’s cheeks. By that time, the ambulance had arrived and we carefully offloaded our little patient and moved her to the ambulance for the ten-minute ride to the hospital. As we rode to the hospital Code 3, Carrie started her secondary assessment now that the airway was secured.
Many people don’t understand the seemingly chaotic sequence of events on an EMS call. There is a specific, well-rehearsed, choreographed routine that always begins with the ABC of a primary survey: Airway, Breathing and Circulation. (Some would add D for disability: ensuring adequate cervical spine precautions to prevent damage to the spinal cord.) Once the primary assessment is complete—and only when it’s complete—we proceed to the secondary assessment, which incorporates a head-to-toe systems survey to evaluate head, chest, abdomen, pelvic and other injuries. Some wonder why we seemingly ignore spectacular wounds, but the answer is simple: a patient is in danger of imminent arrest if they are not breathing or have little or no blood pressure, and this becomes a priority. We disregard everything else is until the primary survey is complete and any problems are dealt with. Nobody ever died from a broken leg in the first half-hour.
It is possible—and it has happened to me—to be unaware of a fractured ankle on a trauma patient because I never got past the airway step. Along the same lines, for example, an enucleated eye is a spectacular injury, and intensely unnerving. But we don’t really care about the eye initially, except to try and protect it from further injury by covering the globe with a moistened saline dressing. I’m far more interested in the fact that somebody had to undergo a great deal of force to the head to produce that injury, and therefore has probably suffered a brain injury. Trauma care is about understanding of how a human body reacts to outside forces, whether a bullet, a car accident, fall or burn. If we can understand the forces, we can anticipate injuries, prioritize them, starting with the ones that will kill you first.