Beth and I were taking our usual afternoon siesta at Camp CALSTAR, enjoying the warm summer sun. We had been on a scene call earlier in the day and the patient’s injuries were relatively minor. But I had that flying feeling, and the sense that something evil was looming.
Simultaneously the beepers went off and the phone rang. I swung off the bed, grabbing the receiver. “CALSTAR One, you’ve been dispatched for a motor vehicle accident on Pacheco Pass. The map coordinates are Santa Clara County page 64, grid B4. You will be talking to Morgan Hill CDF on local net, who will direct you to the frequency the accident is working. Be advised this is a multi-casualty incident.”
“Copy that. Our ETA is seventeen minutes after liftoff,” I said, struggling into my flight suit.
As we flew toward the scene, Beth, who was flying secondary, started making radio calls to contact the ground units. “CDF Morgan Hill, this is CALSTAR One. Ready to copy frequency for ground contact on Pacheco Pass incident.”
“CALSTAR One, this is Morgan Hill CDF. Your ground contact will be Engine 4145 on this frequency. How do you copy?”
“That’s a good copy for CALSTAR One, thanks.” We were still five minutes away, and although we could hear the radio traffic from the scene, we couldn’t talk to them until we were past the last ridge line, when we’d be essentially on top of the accident. That wouldn’t give us much time. It really didn’t matter. We’d know the story soon enough.
As we were flying up the last valley toward the pass, we could see the traffic backing up below. “This one must be pretty bad,” Beth said. “They’re not letting anybody through.” We kept following the road, and as we came around a corner, the accident popped into view. There were two cars on the side of the road completely trashed, and another one rolled in a ditch. A double-trailer semi truck was jackknifed across the road, completely blocking traffic.
I had to giggle a bit. “I’ll bet CHP is going nuts.” The California Highway Patrol seems to have only one goal — to keep traffic moving at all costs. This accident must be giving them ulcers, I thought, as it was obvious this road would be blocked up a good while.
Beth grinned. “Engine 4145, this is CALSTAR One. We are overhead incident. Where would you like us?”
On a scene call, establishing an LZ was usually the responsibility of the fire department. They would radio to tell us exactly where on the scene they wanted us, point out any obstructions like power lines, poles or light standards, advise us of wind direction and speed, and indicate the type of surface we’d be landing on. This time a familiar voice answered us. “Uh, CALSTARrrrrssss, this is Engine 4145. I’m right here. Come on down.”
“Oh, God,” Beth muttered. “It’s Frank.”
Frank was a firefighter with the California Division of Forestry (CDF), a well-trained group whose main duty is to battle summer wildfires in isolated areas, as well as manage areas that are too sparsely populated to maintain a municipal firehouse. The core staff is a remarkably talented group, and in the summer it’s supplemented by young people who are paid only a paltry wage for the grueling and dangerous work of fighting wildfires. They do this to gain experience in hopes of landing a job as a municipal firefighter—or possibly from some twisted sense of responsibility to the environment. In the off-season, these departments run a skeleton staff of full-timers and respond to county calls that are out of the jurisdiction of neighboring fire departments. On the whole, these men and women are heroes, risking their lives for very little compensation.
But Frank was different. He was one of the good ol’ boys the department didn’t have the heart to retire. Certainly he was a decent and delightful man, but utterly incapable of setting up a landing zone. Our first clue to Frank’s incompetence was his insistence upon referring to us as “CALSTARrrrrssss.”
Beth attempted to decode what Frank meant by being “right here.” More than twenty yellow fire coats milled about below us. “Engine 4145, this is CALSTAR. We see quite a few firefighters on scene, and we’re not sure which one is you.”
“CALSTARrrrrssss, I’m not at the accident. I’m in the green field down the road.” We looked around at green fields stretching for miles in all directions.
Beth tried again. “Engine 4145, are you north or south of the scene, and do you have any landmarks nearby? We do not have a visual on you.”
“CALSTARrrrrssss, I’m in a green field with a white fence. You’re on my left,” he replied.
Well, that certainly helped. All the fields were green with white fences, and which way was his left? “Engine 4145, do you have us in sight? If so, please tell us to turn right or left. I repeat, we do not have a visual on you.”
This time there was a slight pause. “Nope. Can’t see you. But I can hear you, I think.”
Tim, our pilot, was getting exasperated. “Beth, let me try. Maybe I can get this guy to understand.” He keyed up the mike. “Engine 4145. This is the CALSTAR pilot. We are currently circling the scene. We have green fields with white fences stretching for miles in both directions. I am going to head south on Highway 152, away from the accident, towards Hollister. Are we headed for you?”
“Yup,” was Frank’s only reply.
“OK, everybody,” Tim said, keying up the intercom. “Look for a dipshit in a field holding a radio. That’s got to be him.” We flew on in silence for a few minutes, with all eyes straining to pick up a fire engine off the road.
“Dipshit in field at two o’clock,” Beth said. “I got him on the right side. Sure enough, he’s in a green field with a white fence.”
“Well, I’m glad he got something right,” Tim said. He swung the helicopter to the right to take a look. “All right, I have him. I’m going to try and get landing zone instructions.” He keyed the radio to the ground. “Engine 4145, we believe we are overhead your location. Do you have us in sight?”
“CALSTARrrrrssss, I can see you now. Yup, this is your LZ. Come on down.” I could see him waving his arms and pointing to the small field where he was standing.
“Engine 4145, do you have any obstructions and can you give us an idea of wind direction and speed?”
“I don’t think there’s any wires, and there sure is a pretty strong breeze down here,” our nemesis replied.
“Tim, there’s a flag over there,” Beth said, pointing to a nearby barn. That would give us an idea of what the winds were doing. None of us believed Frank when he said there were no obstructions.
“Yeah, I just saw that,” Tim said. “I’ve been in here before, so I feel pretty comfortable. Let’s make a quick pass to take a look. But everybody keep heads up on final, OK?”
As we circled, all looked clear and Tim turned final. “Engine 4145, we are on short final approach. Please clear the LZ.”
Frank continued to stand in the middle of the LZ, wildly gesturing at his feet, exactly where we needed to land.
“4145, you are standing where the helicopter needs to be. Please move off the LZ.”
“Oh, yeah. OK.” Frank ambled off toward his fire truck.
As we landed, I grabbed the adult trauma bag. “You don’t think we’re getting a pediatric patient, do you?” I asked Beth. Our pediatric supplies were in a separate bag in the back.
“No,” she said. “We’ve drilled it into all the fire departments to give us a heads-up with pedi patients. Even Frank knows that.” I nodded, unbelted, and climbed down the skid to the ground. I walked over to where Frank was standing.
“Hi, Frank,” I said. “How are you doing?” I was tempted to give him a lecture on how to land a helicopter, but stopped myself. This wasn’t the place.
“Good to see ya again,” he replied. “Hey, are you guys coming to the barbecue next week?” he asked, clearly unconcerned with our approaching patient.
An ambulance came around the corner, with lights and siren on, and pulled heavily into the field. I glanced over at the helicopter, which was still running. Beth had the litter out and was standing and talking with Tim. I motioned to her and she nodded. I walked to the back of the ambulance, opened the door, then stood dumbly staring at the interior.
Mother of God, it was a toddler. In full arrest. I looked down at my adult trauma bag, which was now completely useless. Frank stood beside me, grinning.
I carefully turned to him, trying to control my rage. I enunciated through gritted teeth. “Go to my partner, NOW, and tell her to COME IMMEDIATELY. With the PEDIATRIC BAG. Do you understand?” Frank nodded vigorously and scurried off as I climbed into the back of the ambulance.
It was a little girl, probably about three. One medic was assisting her ventilations, and the other was doing chest compressions. I did a quick initial assessment. Both legs were splayed out at unnatural angles, with bones viciously sticking out of the skin. She was just lying on the gurney, with no packaging done. Her face was covered with blood, and her skin had a bluish tinge. On the opposite bench her mother was screaming.
I squeezed past the paramedic doing compressions to the head. “Do you want me to take over ventilations?” I asked.
“Yeah,” he said. “Sorry about this. This is a passenger who was hit head-on by a semi truck at around sixty miles per hour. She was in the back seat with no belt, and when the car rolled, she was ejected. We didn’t even realize she was there until the mother here woke up and started yelling for her. We found her about 150 feet from the car in a ditch. Initially, she had a faint pulse and gasping respirations, but those are gone now. We see injuries to the head, chest, abdomen, and the obvious extremity stuff. We used up all of our equipment with the other patients, and then the incident commander just dumped her on us.”
Beth appeared at the ambulance door and surveyed the scene before her. She didn’t miss a beat. She crawled in, handing the pedi bag up to me, and I quickly gave her the story. “We need to intubate her now,” I said. “You guys start packaging her while I get my stuff together.”
“Do you guys have a backboard?” Beth asked the medic.
“No, I was just explaining to your partner,” he replied, continuing CPR. “Nobody knew she was there until all of the equipment was used up on the other patients at the scene.” Beth looked around the ambulance, then grabbed a short board that is used to provide a firm surface for adult CPR. It would be just long enough to support the little body. She looked up at me. “Are you ready to tube now, or can we roll her onto the board first?”
“Let’s get her on the board first so you guys can finish packaging her while I do the tube,” I answered. “Is everybody ready? On three.” We gently logrolled her onto the board, holding the cervical spine aligned, and with Beth trying in vain to support the horribly disfigured legs. The mother had stopped screaming and was intently watching. I grabbed the laryngoscope and gently placed it into the child’s mouth, which was filled with blood. “I need suction,” I said, and held up my hand, hoping the medic or Beth would anticipate the need and be able to help while I kept my eyes on the girl. There was no suction. I looked up and saw the medic frantically pounding on the switch, but it was not responding.
“It’s not working,” he said. “I can’t believe this.”
I resumed bagging with the mask. “Beth, I can’t get this tube without suction to clear out all this blood. I’m just going to hand-ventilate her until we get to the aircraft. We’ll do it en route. That OK with you?” We both knew this child had no chance for survival, but we couldn’t give up on her, especially with the mother in the ambulance witnessing this awful spectacle.
“Sounds like that’s our only option,” she said. “I’ll do compressions until we get en route.”
We started off to the aircraft, which was still running. Only ten minutes had elapsed since we had landed, but it seemed like an eternity. As we loaded the girl in, I yelled at Tim. “As soon as we get airborne, call dispatch and tell them we’re coming with a three-year-old blunt traumatic arrest. We’re going to be too busy to give a report.” He nodded his head and reached over to help load the litter.
In the air I started suctioning out her mouth and grabbed the laryngoscope, saying a brief prayer to the intubation gods. Thankfully, I could now see the vocal cords and was able to pass the endotracheal tube. As we started bagging her, her chest rose and fell with each breath, and our ETCO2 detector turned a reassuring yellow, indicating the tube was in the right spot.
Beth, who had been doing compressions, reached over and switched us to hot mike, so we could talk over the intercom with hands free. “Do you want me to start an intraosseous line now?” An intraosseous line works like an IV, except that it’s placed directly into the bone of young children. Young children’s bone marrow is soft and vascular, so any fluids or medications are easily absorbed. And the bones are a much larger target than a tiny scalp or hand vein.
“Yeah,” I nodded. “Looks like the only place to go is the right femur. Everything else is pulverized. I’ll do compressions.” She nodded. After the line was established, she gave the first round of medications and started pushing fluids. We checked the monitor. Where only a flat line had been, we now had a rhythm. “Do we have pulses?” I asked.
Beth reached down and felt for the femoral. “I don’t believe it,” she said. “We’ve got a pulse. Let me check a pressure. Stop compressions.” To our amazement, it read 80/30. We were landing at the trauma center.
As we unloaded, the trauma team met us at the helipad. The trauma surgeon and pediatrician took a quick look at our patient. “We heard this was a blunt traumatic arrest,” yelled the pediatrician over the noise of the rotor blades. “Did you get anything back en route?”
“It’s hard to believe,” I yelled back, “but we have a rhythm and a blood pressure.” We ran into the trauma room, where the entire team swung into action. As they were hooking her up to the monitors, she arrested again. This time they did not get her back.
Later that day, we received a call from a CHP officer who was working the scene. His investigation was now being treated as a homicide. Apparently, mom had gotten into a fight with the boyfriend and, after drinking a pint of vodka, decided it was time to leave. She had “forgotten” to put the seat belt on her little girl.
Looking back, I know that even if we had landed routinely and hadn’t needed to return to the helicopter for the pediatric bag, no intervention would have saved that girl. But we did learn an important lesson that day with Frank: Never assume anything. Since I didn’t get the message on that flight, I learned it all over again sometime later.
That particular night, the phone had jarred us awake at 3:00 a.m. Lunging for it, I managed to send both the phone and the bedside lamp crashing to the floor. “Where are we going?” I mumbled. Nancy was stumbling around the room in the dark, groping for her flight suit.
Elise, our dispatcher, informed us we were going to Yosemite General, a small hospital in the mountains near Yosemite National Park, more than an hour away. We were to pick up a patient and bring him back to Children’s Hospital in Oakland. “You’ve been activated for a two-week-old infant with a diagnosis of omphalitis,” she said.
“Omphalitis?” I asked. “What in heaven’s name is that?”
“O-M-P-H-A-L-I-T-I-S,” she spelled. “Apparently it’s an infected bellybutton.”
As I dressed, I mentally sorted through all the potentially disastrous or life-threatening pediatric conditions I could think of. Let’s see—meningitis, congenital anomalies, trauma, respiratory infection, and shock. None of these possibly lethal conditions fit with an infected bellybutton. Sighing, I reached for my flight suit and jump boots. I didn’t see any way we could turf this call, as the sky was clear and starlit—perfect flying weather. Occasionally, Children’s Hospital would call us to transport non-critical patients, and in keeping with CALSTAR’s philosophy of “you call, we haul,” we were obliged even when it seemed an unnecessary use of an emergency resource.
We headed out to the helicopter muttering obscenities. “What are we going after?” Nancy asked, wiping the sleep out of her eyes.
“You’ll never believe this,” I said. “It’s a two-week-old with an infected bellybutton.”
Nancy was one of the newer flight nurses, born and raised in New York. She spoke with a heavy Long Island accent and had an attitude to match. “You gotta be kidding me,” she said. “These guys dragged me out of bed for a goddamn infected bellybutton? What is this shit?” J.B. wasn’t happy about piloting a long middle-of-the-night flight either.
The three of us climbed into the helicopter and lifted off. The flight was quiet, punctuated only by the necessary communications. We flew over the San Joaquin Valley, then up into the foothills of the Sierra, where Tuolumne is located. I was still puzzled by the bellybutton and wondered if maybe I was missing something here. I pulled out the pediatric transport resource book to see if omphalitis was discussed. It wasn’t, which meant that when we got back to Children’s some first-year resident was going to get an earful from me regarding the appropriate use of an emergency helicopter.
An hour later, we landed at the local airport, because Yosemite General Hospital doesn’t have a helipad. We had called an ambulance for the twenty-minute drive, and the crew that met us looked like they had been through a meat grinder. Their uniforms were wrinkled and smelly, and they regarded us with bloodshot eyes.
“What are you here for?” one of them asked wearily as we loaded all our equipment onto their litter.
“An infected bellybutton,” I replied. Disgust clouded his face.
“Let me get this right,” he said. “You got us out of bed at this ungodly hour for an infected bellybutton?”
“I’m sorry,” I said. “This call will definitely be flagged for review with the Children’s transport committee.” The only reply was a grunt from the front of the ambulance.
When we arrived at Yosemite General, we were met at the back door by a very nervous young pediatrician. He slung his arm around my shoulder, propelling me toward an exam room. He pushed the chart into my hands, speaking rapidly. “For now, all of his labs are normal, but I’m considering repeating the blood gases to see if there is a change. I’ve started him on triple antibiotics, but we may send you with another dose. I’m really worried about this kid. Do you think you can expedite this transport?”
“Why don’t you let us take a look at him first,” I suggested. Patience is not one of my virtues, especially at 3:00 a.m., and I was already exasperated with this nervous little man. I looked over at Nancy, who just rolled her eyes.
As I walked into the exam room, all of my expectations were confirmed. There, in his mother’s arms, was the cutest, pinkest little baby I had ever seen, sucking contentedly on a pacifier. He turned toward us as we entered the room, then concentrated again on his Nuk. His parents, obviously worried, watched us carefully.
“Is he going to be OK?” the young mother asked. I could see the panic in her eyes, which was clearly being made worse by the anxious pediatrician hovering behind me.
“From where I stand, he looks wonderful,” I replied. “Could you put him down on the gurney so we can get a good look at him, please?” She laid the baby down and I carefully unwrapped him. His skin signs were great, his pulses were bounding, and his vital signs were all completely normal, including his temperature. So far as I could see, this little guy was in better shape than I was. When I took off his diaper, I saw what all the fuss was about. Surrounding the umbilicus was a pocket of pus, and the stump itself was red, with a small amount of greenish drainage. The rest of the child, however, was in splendid form. His IV was in place and infusing well, and he had received the necessary antibiotics.
I turned to the parents, who were watching us intently. “He’s going to be fine,” I said. “We’ll just run him down to Children’s, and they’ll take very good care of him. He looks like a special little boy. Your first, right?”
They nodded. “He was kind of unexpected,” the dad said. “But you know, you get pretty attached to these guys.”
We got busy hooking the baby to all the monitors. While Nancy finished packaging the little boy, I called Children’s to give them a report. To add to my frustration, nobody could find the night resident. I listened to annoying Muzak for ten minutes, impatiently tapping a pencil on the desk. Finally I hung up and called the ICU again. I spoke with the charge nurse and gave her a brief report of what we had seen. I told her to let the resident know we were en route, and if he had any further orders to contact us via dispatch.
When I got back to the exam room, Nancy had the baby all ready to go. We didn’t take families on flights unless it was an unusual situation. There’s not much room in the helicopter—they would have had to fly in the front seat, where they would have access to the flight controls, so the pilots considered it a safety issue.
On the medical side, we didn’t want the family there in case something went wrong. If the patient arrested, the family would be stuck in the helicopter with us, listening to everything we were doing, some of which can be pretty unnerving. And we’d need to concentrate on the patient without being distracted by a hysterical family member. One of the few times I did allow a parent to fly along, I ended up taking care of her as well. She became so violently airsick that we had to start an IV and give her medication to treat the nausea.
I reassured the parents and encouraged them to be careful on the treacherous drive out of the mountains. It would take them three or four hours to drive to Oakland. “As a matter of fact, why don’t you go home and take a shower and pack a few things,” I suggested. “The staff at the hospital can manage till you get there.”
Our anxious pediatrician hovered in the background, occasionally imploring us to hurry, which only annoyed me further. We had only been there for twenty minutes, and we were moving as fast as we could. We certainly weren’t going to dawdle. Our beds were waiting.
The grumpy ambulance crew took us back to the helicopter. The baby promptly fell asleep after liftoff. He woke up once and became a little fussy, but was quickly soothed with his pacifier. I found myself nodding off at one point, and shook my head to concentrate on our little patient.
When we arrived at Children’s, I was a bit testy in giving my report to the staff. “I’m not sure why this guy had to come down by helicopter tonight, but here he is. His vital signs are stable, and his perfusion is great. We’re going home. We’ll call later and see how he’s doing, OK?” I figured that by the time I made the call the baby would be out of the ICU.
As we were walking out of the ER, the early morning sun was just peeking through the Oakland Hills. “You know,” Nancy said, “there’s something depressing about watching a sunrise without an all-night party and an imminently righteous hangover to show for it.”
“Or at least a righteous flight,” I said.
J.B. was waiting for us at the helicopter.
“How’s the baby doing?” he asked
“I’d say better than us,” I replied. “Can we go home now?”
A day later I was back at CALSTAR still fuming at what seemed to me a wasteful flight. I was preparing to phone the transport coordinator at Children’s and give her this opinion, but before doing that I wanted to call and see if the baby was already out on the floor, or perhaps even discharged as I expected. Dolores, the unit secretary, answered the phone.
“Hi, Dolores. It’s Janice from CALSTAR. How’s things over there this morning?”
“It’s really busy right now,” she answered. “We’ve got dueling codes going on and everybody is going berserk.” In medical jargon, a code—or code blue—is a cardiac arrest, and it also refers to the sequence of events we follow in trying to resuscitate the patient.
“Sorry to hear that. I’ll make this short. Do you know where the baby is we brought down early yesterday morning? He had an infected bellybutton. From Yosemite.”
“I hate to tell you this, but he’s one of the codes. He arrested about twenty minutes ago.”
The floor opened up and swallowed me. “Oh my God, Dolores, what happened?” I whispered.
“I don’t know exactly. I think I heard somebody talking about florid septic shock. Does that make sense?”
I thanked her and hung up, realizing she was too busy to be chatting on the phone. Nancy, who was back with me for another shift, saw the expression on my face. “What happened?” she demanded.
“They’re coding him. He’s in septic shock.” At that moment, I couldn’t get any more words out. We had been bitching for the entire flight about this infected bellybutton. And now he was dying. Worse than that, I had reassured the parents that all was well, fine, no problem. Now they were sitting outside in the lounge waiting to hear if their firstborn son was dead.
In the end, our worst fears came true. The little boy died later that afternoon, despite aggressive, heroic efforts. It seems that an infected bellybutton in a newborn is a superhighway for bacteria to get into the central circulation. A very young child’s immune system can’t manage an onslaught of virulent bugs. The presence of such a large pocket of pus was an indication of how extensive his infection had gotten. The anxious pediatrician at Yosemite General had every reason for his concern.
I don’t think we could or would have done anything differently from a medical standpoint—he got to a specialized pediatric hospital quickly. But this flight taught me another lesson: Never, ever cop an attitude. It only reveals your ignorance.