i’m not a complicated person.  but i’m a very emotional guy.

i feel fortunate and humbled for the path my life has lead me down.  the attraction which led me into EMS in the first place eventually drew me towards the east coast for college.  while there, i built a solid foundation as a paramedic and earned a bachelors degree.  that led to more open doors in the clinical arena. 

craving true critical care experience and autonomous practice, eventually, i entered an organ procurement organization (OPO) as the first organ procurement coordinator who was not a RN, NP or PA-C. 

in the time i spent at the OPO, i was exposed to air medical services on virtually a daily basis.  the twin helipads were outside my window, and i watched various flight services transport adult and pediatric patients to the level I adult & pediatric trauma center.  after about 36 months of observing and researching — and a little prodding from the flight crews, i had decided it was the next logical career step for me.

i applied locally, then regionally, then east of the mississippi to various flight programs.  i sought out programs that i felt i would be a good match with.  nearly 20 months passed before i finally got the elusive third interview and was hired.

during my last week on the job as an organ coordinator, i worked a case in which we procured multiple organs from a donor in metropolitan milwaukee.  the case was rather protracted, and took around 24 hours total to complete donor evaluation, place all of the suitable organs for transplant and finally get all of the teams to the OR for organ recovery.

before rotating off at 0800 on june 4, 2007, i had placed all organs except for the heart and pancreas.  i had earlier placed both lungs with the university of michigan transplant program (MIUM TX-1) .  the remainder of the organs were placed with local transplant centers (milwaukee area centers).  exhausted, i passed off report to the relief coordinator, drove home, and collapsed into bed around 0915.

around 1700, i was awakened by my wife shaking me.  i remembered walking the dogs around 1400, and i never woke up to eat dinner after being up for 24 hours straight.  she grabbed my hand and pulled me upright in the bed.  i felt a surge of annoyance. 

“you need to come out to the TV,” was all she said.

so i did.  and my blackberry was just buzzing and flashing nonstop with unread texts, emails and missed calls/voicemails.  i sat down on the couch and just started watching:

http://www.clickondetroit.com/news/13441002/detail.html

one week later,  june 11th, 2007, i started my current rotor-wing HEMS job. 

i keep the memory of MIUM TX-1 team members David Ashburn, MD; Martinus Spoor, MD; Richard Chenault, Rick LaPensee, Dennis Hoyes  and Bill Serra with me every day.  learn about them here: 

http://www.med.umich.edu/survival_flight/update/bios.htm

these were six truly talented, gifted, focused and dedicated individuals.  i never met any of them personally.  my relief organ coordinator met and interacted with most of the team for an extended period in the OR.  but i do thank them for helping me to live life with my eyes wide open, helping me to realize how your professional choices can so profoundly affect your personal life, and showing me why i should take absolutely nothing for granted whether i’m working as a flight paramedic or an organ transplant coordinator. 

words, sculptures and other platitudes seem grossly inadequate for all of us in the transplant/EMS community to express how much you are missed and how poorer the lives of so many will be in your absence.

hail to the victors valiant!

last week, we were requested on a scene flight 14 miles west of our base. reported to be a head on crash involving two vehicles at high speed, the pagers went off just as the sun was beginning to set.  like every other call, we checked weather, accepted the mission, packed up our Oneg blood and went out to the aircraft .

as i did my walk-around, i mentally went over some of the possibilities of injury mechanisms, interventions and little time saving tricks to minimize our on-scene time and get us in the air towards a trauma center.

we pre-flighted and lifted with eyes out, and i shortly thereafter turned my attention towards calculating rapid sequence intubation medication dosing for a 180 pound individual.  shortly, we arrived over the scene and started our recon orbits.  below were two cars, front ends heavily damaged, one up on its right side.

we put down in the roadway and hot unloaded out stretcher and gear, and walked past the two vehicles.  i noticed the panoramic sunroof was open in the car which was tipped up on its right side and down in the ditch there was a mess of trampled grass, mud and medical debris. 

our patient was in the back of the ambulance so we entered to find an alert, oriented to person/place/time teenage boy who was muddy, scraped/bloody but otherwise appeared unscathed.  report was given to us by EMS as follows:

“17MC unrestrained driver traveling approximately 50 mph crossed center line and struck vehicle off-center/head-on, causing his car to be flipped up on the right side.  victim was thrown about interior and ejected through sunroof into ditch.  found supine and initially unconscious by witnesses and a sheriff’s deputy.  remembered the events leading up to the accident.  initial EMS findings:  GCS 14 | 128/50 | 48 sinus brady | 14 clear non/labored | 99% O2 sat room air.”  collared/LBB/packaged prior to our arrival and two large bore peripheral IV’s were running wide along with a NRB @ 15LPM before we even climbed into the ambulance.

our primary and secondary exams revealed a very athletic young man complaining of mid/lower back pain, some sternal discomfort without dyspnea, right hand/wrist deformity/swelling and a few soft tissue lacerations involving his right side.  no major injuries detected, and scored 15 on our glasgow exam twice over. 

my partner and i were both feeling pretty good about this kid given the circumstances of the accident, tremendous energy transfer, no safety belt usage and ejection with positive loss of consciousness.  one of the scene paramedics confided to us he was the local high school starting quarterback and as i was weighing for a second whether or not he was right handed, the patient looked up into my eyes and asked the question:

“am i going to die?”

my mind immediately flashed back to my formative days as a paramedic on the east coast, working in an urban system where we ran from sunup to…well, sunup.  along the way, i met the most colorful characters – including the regulars - which made up the fabric of my shift life.

one of those people was brankho, a second generation eastern european who worked in the shipyards of the far east side almost 35 years.  built like a brick shithouse – but a gentle soul – he was on the dark side of his 60′s when i first encountered him short of breath outside a shipbuilders union hall.  over the next three years, i learned that he drank heavily, was hypertensive, had asbestosis, almost never saw the doctor and suffered from what i perceived to be virtually omnipresent kidney stones. 

it was the kidney stones passing that caused us to encounter brankho the most.  our medic unit would run at least twice a month to either his residence or the union hall for a sick person/abdominal pain call.  inevitably, he would be intoxicated to some degree and in a great deal of pain.  for four years we would manage his pain with morphine in the field and transport him about eight minutes to the nearest hospital, since he would frequently be too intoxicated to refuse transport.

on a still august night with the humidity and temperature both around 85, i had barely began to enjoy the air conditioning of the day room at our station after a long day of running the streets when the house tones rang for severe abdominal pain at brankho’s home address.  usually, i would just look at the clock and block out an hour to complete this predictable run, but i found myself annoyed.  three shifts ago, i had just taken him in for kidney stones and figured we wouldn’t be hearing from him for a couple weeks.

strangely, he wasn’t on the front stoop of his neatly manicured shotgun bungalow when we pulled up.  the front door was cracked and, mercifully, the air conditioner was on full blast inside.  brankho was in the bathroom slumped against the wall, boxers down around his ankles – diaphoretic, pale short of breath per normal and complaining of severe bilateral flank pain extending down into his genitals.  a quick BP showed 240/110 and i looked over into the open toliet bowl and saw some concentrated urine streaked with blood.  in clipped phrases, he conveyed to me that he was voiding to pass a kidney stone and just passed out.

my partner and i each locked an armpit and assisted brahnko to his feet.  i could instantly tell that he had been drinking, but he didn’t seem intoxicated.  we assisted him a few woozy steps towards the stretcher and his visible pain seemed to be worse than i ever remembered.  i wondered if his ureter was obstructed. 

when we were one step away from the stretcher, brankho’s knees buckled.  in a practiced dance move, my partner and i managed to spin brankho around and plant his ass squarely on the cot.  i wrestled his upper body while felicia managed his legs into the accepted position.  the back of the cot came up to semi-fowlers.  we clicked the seatbelts, and i was just about to pull away when brankho lazily waved his hand across mine and looked me in the eyes, raspily asking the question:

“am i going to die?”

and as i started to answer brahnko that he would not die, his eyes rolled up with a quick burst of seizure activity.  ten seconds later he was still, apneic and pulseless. 

felicia called for engine 61 and an ems supervisor.  we flew out to the ambulance with CPR in progress and started working brankho – monitor, IV, tube. 

his intial rhythm was PEA and continued on that way for nearly 15 minutes until the complexes got wider. and then we were almost to the hospital and it looked like asystole.  we tried everything at our disposal, even pacing, when we witnessed the line go flat (because it was still acceptable in those days).

brankho died. 

upon autopsy, cause of death was determined to be catastrophic dissection of an existing abdominal aortic aneurysm.  i was devastated that somehow, i had missed this. 

from day one, i never believed that i could save every ill or injured person that emergency medical services brought me into contact with.  but i have never been quite able to hear the question “am i going to die?” from any patient without suddenly being taken back to that night in august nearly fifteen years ago.

i finally answered my patient in the ambulance (after what probably seemed like an eternity to him) by saying on the outside he looked fine, but that i couldn’t see what was going on inside his head and body after being thrown from a car at high speed.  he seemed satisfied with my reassurance, but probably wondered if i was suffering from vapor lock since it took me almost a full fifteen seconds to process his question, flashback and answer it.  i know my flight nurse gave me one of those “wtf? that was lame…you glassy-eyed freak.” looks.

we flew our football star to the crystal palace for trauma evaluation.  his throwing hand and wrist turned out to be OK.  but he had multiple spine fractures, a cardiac contusion, bilateral pulmonary contusions and abdominal organ injuries.  he required surgical intervention and was discharged from the hospital at post-operative day #10.

another blogger i follow brought to light earlier this year that helicopter emergency medical services (HEMS) is one of the most dangerous professions.

 its socially acceptable to send photojournalists on crab ships in the north pacific and film crab fishermen on tiny commercial ships working brutal hours under abhorrent conditions while being maimed and/or swept overboard.  they become entertaining collateral damage of sorts.  compelling television, isn’t it? 

a certain reality network has made a hit show from the misfortunes of these workers — many completely green — toiling for an industry with little regulation, operating in a zero-error margin environment, while racing the clock to meet their quota. 

i can at least point out for the tremendously dangerous work these sacrificial crabbers perform, for a relatively short period of time, the payout for their seafood catch is eye popping.  

now, try doing that with an air medical crew.  attempt to put any photojournalist on an over water/over rural/over mountainous terrain flight at 0312 hours with minimum visibility, no point of reference, wind gusts of 30 knots at 1,000 feet and i’d say good luck on getting that photojournalist to stay onboard for very long.  no one wants to record their own demise.

but as flight crewmembers we do it all the time in HEMS, because it is often what the mission calls for, right? 

as you sit here and read this, i’m sure you’re saying: “i wouldn’t get aboard that aircraft…I’d turn that flight request down”.  well — everyone’s the proverbial monday morning quarterback.  but over the past three years, I can show you example after example of:

-pilots who thought the weather wasn’t that bad
-pilots who flew into poor weather and, rather than turn around, pressed on
-pilots who became disoriented in rural areas with no points of reference at night
-pilots who became overwhelmed with changing weather conditions and lost track of what was going on outside the aircraft
-pilots who failed to maintain adequate clearance with other aircraft, terrain or obstacles

think i’m picking on pilots?  never fear, I’m an equal opportunity finger pointer:  in virtually every one of these cases i‘m speaking of, the air medical crew obviously failed to speak up and say something.  or anything.  they sat idly by for who knows what reasons and died.

i’ve been on the job a relatively short time compared to many of my flight crew members.  as a matter of fact, at my base, i am absolutely the fucking new guy.  but i’ve turned down a flight during my first 24 months on the job — actually two of them.  and i’ve been on two other flights where i wasn’t up front and the flight nurse decided it didn’t look so hot ahead, so we changed our magnetic heading 180 degrees and went back to base.  no questions asked.

it boils down to equally poor judgment by motivated, qualified, experienced pilots and notoriously type-A, hyper-aware, uber-trained medical flight crew members.  don’t believe me?  read summaries of air medical helicopter accidents over the past three years on the NTSB website.

the FAA in february 2009 held extensive hearings into the operations of HEMS.  this was brought about by the abysmal safety track record the HEMS industry has managed to carve out for itself through voluntary compliance.  basically, hems does a shitty job of looking out for its own.

several days of testimony were offered by industry experts, hems operators, pilots, and even air medical crash family members.  some of the video i watched was unbelievably boring.  some of it was laughable.  a lot of the data and facts were embarrassing.  some of it was spellbinding.  parts of the testimony raised additional questions.  certain areas of it left me feeling empty about HEMS as an industry on the whole.

as a result, the solution has shifted to the FAA now policing the air medical industry through mandatory safety measures which will be implemented sometime around 2011 following an in-progress open comment period.

so how far have we come?  we have helicopters out there in excess of $6 million USD that virtually fly themselves.  we have airline transport rated, IFR qualified pilots with thousands of hours of turbine time and multiple instructor ratings.  we have medical crew members, many who have spent 15-20 years in emergency or critical care medicine, hold every specialty certification, instructor card, are board certified as flight nurses or flight paramedics and are so detail oriented that virtually nothing slips by them. 

and the accident rate is still unacceptable.

prepare to hear air medical operators whine over and over about increased cost, estimated to be around $100,000 per helicopter to meet these proposed FAA federal safety  standards.  but it’s gotta be cheaper than civil litigation.  i understand the aggregate cost to large operators like air methods, phi and omniflight — it’s a multimillion dollar proposition and an enormous logistical undertaking.

on the other hand, callous HEMS operators like air evac lifeteam, which have been documented spending thousands of dollars lobbying against stricter safety standards because it would cost them more money against their bottom line are about to get a well-deserved foot up the ass.  guess its true what they say about karma, after all.

but until the FAA is able to sink its teeth in, how good is HEMS?  because right now, i’d rate us as an industry with little regulation, operating in a zero-error margin environment, while racing the clock to meet our quota.  (and the crab fishermen are ahead because they make much better money).

without this impending safety upgrade mandate by the FAA, i have no doubt that air medical flight crews, and, sometimes their patients, would have continued to perish at an alarming rate during 2009 and in the years to come.  as smart as we offer ourselves up to be:  well-trained, indoctrinated in crew resource management, conditioned to put safety before all else — face it —our track record sucks.

sometimes, to find the root of the problem as well as the solution, you need only look into the mirror.

i don’t know what you’ve heard, but i’ve been regaled with endless descriptions from EMS providers, firefighters and flight crew members about what working a 24 hour shift is really like over the years.

inevitably, these descriptions are elicited by a request from someone who isn’t on the job yet or hasn’t been exposed to that level of clinical intensity so far, or often a civilian.  other reasons to start spouting these types of descriptions off include:   someone wanting to ride along, a student tour of a station/base, or sadly…a pick-up gone bad in a bar magnified by way too many captain morgan and cokes.

some of my personal favorites?  let me share:

“weekends are more exciting, sometimes”
“it’s feast or famine”
“we go several shifts with nothing and then run our asses off”
“things pick up during the summer”
“we see more suicides during the holiday season”
“it was good, but since they dropped our package back to basic cable it’s been hell”
“I never make my bunk up on tuesday nights.  we just run and run”

whoa.  i need my personal airsickness bag, hold on a sec…

but my all time favorite are the folks who put it into a time management format.  the time management format goes something like this:

“it’s 16 hours of boredom, 4 hours of hard work, 3 hours intense concentration and one hour of insanity”.

really?

in the interest of providing an accurate portrayal of what an actual flight can be like from a first person perspective, I’d like to submit my timeline from a flight last month…63 minutes from dispatch to transfer of care at the receiving facility.

1351 – pager goes off.  bladder full.
1352 – furiously struggling to slug remaining energy drink while peeing and talking with my partner through the door.  it’s a GSW to the abdomen, nothing else is known.
1353 – (carefully) zipping up flight suit and washing hands.  insert altoids in mouth, apply chapstick to lips.  sleeves unrolled.  checking weather and walking out to hangar.
1354 – slip syringe pouch and bougie into my leg pocket.  partner emerges from crew room into hangar with cooler full of O negative blood.  helmet on, clear shield down, fumbling with chinstrap…
1355 – out to apron.  pilot’s walk-around already completed and operational control authorization granted.  doing my walk around.  fucking chinstrap!  nomex gloves out of the pocket.  pilot yells clear and engine one pukes some raw jet fuel vapors.  it sounds like starting a gas grill, only much louder.  the main rotors start turning left and the tail rotor spins clockwise.  blood secured aft of pilot.  nurse strapping herself into co-pilot’s seat.
1356 – engine two spooling now.  plugging into the carter box and sit behind the co-pilot.  the pilot’s mic is hot and he’s going through his checklists while airport ATIS drones competitively.  i’m trying to filter one out and listen to the other with no preference.  my seatbelts are on.  second shaded visor or sunglasses? (second shaded visor today, there are no clouds).  nomex gloves on…ahhhh…chinstrap.
1357 – acknowledging to comms we are lifting.  tower clearance for takeoff and turnout to the south.  sterile (silent) cockpit.
1358 – lifting with three souls, 6 minute ETA, and 1’50” on the fuel.  eyes out.  the main rotors make a crazy strobe light flicker stream in the west window.
1359 – update from comms:  a middle aged female with a chronic illness, self inflicted gunshot wound to the LUQ of her abdomen about 35 minutes ago.  arriving at the referring facility now.  no other information.
1400 – calculating RSI dosing on cloth tape torn into strips and attached to my left leg.  struggling here…she’s chronically ill but strong enough to fire a gun?  40 kilos? 45 kilos? 
1401 – pilot is on the radio talking with receiving hospital to ensure our helipad is secure.  update from ED:  they’re having ‘difficulty’ finding a blood pressure and are intubating the patient now.
1402 – we pass a small uncontrolled airport with a fairly busy flight training program.  i’m looking back out again for any signs of danger.  i’m suddenly thirsty again.
1403 – pilot lets us know the town and hospital are in sight, landing checks in progress.  a quick review of my equipment on the bench.  i need to take the blood in.
1404 – we’re orbiting.  i see the pad and security standing at the usual pre-determined locations.  landing check is complete. another circle and we turn into the wind and begin our descent.  eyes out.
1405 – sterile cockpit again.  eyes out.  aircraft shakes like a carnival ride.
1406 – touchdown.  flat pitch.  i’m unbuckled, gloves off. side door open, and a rush of rotorwash and regurgitated jet fumes rush in to meet me.  no threats to the aircraft. 
1407 – unbuckling blood.  struggling to disengage the blood cooler from the aft seat behind the pilot.  my partner is already around the back of the aircraft and the clamshells pop open.  my blood cooler miraculously makes it onto the head of the cot and is snapped in.  oxygen secured to the side rail.  releasing the aircraft stretcher bucher bracket and out goes the stretcher.
1408 – i contort myself out the aircraft back and latch closed the clamshell doors kneeling on the helipad.  turning, i follow my flight nurse towards the ED entrance.  my helmet comes off outside the main rotor arc with my back turned and the world becomes 100 dB noisier.  i place it in the grass just inside the helipad fenceline and wonder how my flight nurse is already to the ED sliding door entrance.  maybe I am eating too many pop-tarts?
1409 – gloves on, in through the sliding door and a large crowd is around and behind curtain number two.  an intubated female is being coded with a single GSW visible at the LUQ of her abdomen, mid-clavicular, immediately inferior to her ribcage.  So much for chronically ill (?), she looks to be about 65 kilos to me.  it’s a PEA code, but yet I understand the atropine was the med of choice.
1410 – someone finds a rhythm.  i find an exit wound posteriorly at her left flank with an enormous hematoma involving virtually her entire lower left back.  time to go now.  danielle is checking breath sounds and pulses.  i’m setting up O negative bag number 1.  someone wants us to wait for a CXR read.  i want to, but we have 28 minutes flight time and this person really needs a surgeon.
1411 – patient actually starts flailing around now!  out comes the fentanyl, zofran and nimbex, pressures are hovering in the 80’s so we don’t trust anything else.  our cot is in the doorway and being brought to the bedside.
1412 – our portable transport monitor is being attached.  cycling for a blood pressure, searching for a pulse ox.  i ask for the body bag to be unzipped and opened on the aircraft cot mattress to be a catch basin for the volume of blood I anticipate her to lose during the flight.
1413 – patient on the aircraft cot and secured.  unit number 1 of blood is up.  we need another two IV access lines.  two blankets over the top to conserve heat.  CXR preliminary interpretation appears out of nowhere and looks really normal.
1414 – family at bedside in ED.  we have the very little paperwork, radiological CD and certification of transfer in hand.  patient disconnected from hospital ventilator and on our bag valve mask.
1415 – moving out of the ED to helipad.  oh shit…forgot a quick iStat at the bedside!
1416 – patient placed in aircraft and secured.  breath sounds rechecked.  transport ventilator initiated.  i climb in through the clamshells again and shoehorn myself onto the bench seat.  my helmet has magically appeared from the outside.
1417 – doors slam…i’m all alone in the aircraft, pilot and danielle are doing another walk around before our departure.  the whine of the anti collision strobe power source echoes in the radio system.  buckling in., rechecking the monitor/cycling for a BP while we‘re quiet and still, feeling for femoral and radial pulses.
1418 – vampire syndrome, thinking about another IV site.  danielle comes springing through the port sliding door and grabs the airway seat.  90/39.
1419 – pilot yells clear, engine number one turns. danielle’s helmet goes on and she plugs into the carter box.  setting up end tidal CO2.  think I see something big enough for a 16 lurking along the wrist.
1420 - pilot murmuring through checklists again.  my sleeves are rolled all the way down and fastened, clear visor down for now.  ohhhhhhh – fucking chinstrap again.  engine number two.  i’m fishing in earnest for a 16g hiding in my right leg zipper pocket.  danielle snaps the ETCO2 monitor on the endotracheal tube.
1421 - checklists complete, throttles coming up.  reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish 3mm bilaterally, neuromuscular blockade in place and seems adequate.
1422 – pilot asks us if we are ready in the back.  we are.  eyes out, sterile aircraft environment.  i’m wondering if I have an IV start kit hiding in a leg cuff zipper compartment. ready to lift.  danielle introduces another 50mcg of fentanyl.
1423 - hover check, and then straight up.  forward flight.  92/44.  108.  98%.  35ET.
1424 – no such luck on the IV start kit, but the 16g could not hide.  retrieve an IV start kit from the drawer, spike another blood admin set and extension.
1425 – prep site, identify vein, get a flash, advance cath, retract needle and promptly blow perfect wrist vein.
1426 – danielle grabs an 18fr OGT and piston from our airway bag.  blood unit #1 is approaching empty.  i am armed with a new 16g and seeking an access point on the left side.  reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish to midrange 3mm bilaterally, neuromuscular blockade in place and seems adequate.
1427 – blood unit #2 matched, spiked, recorded and stickered onto the run sheet.
1428 - OGT disappearing down the hatch.  i’m playing go fish for something/anything in the antecubital area.  a lazy flash pushes up the needle bore, giving me hope.  off goes the catheter.  flush, it’s patent.  it’s secured.  up goes bag #3 of warmed fluid, noted with my amazing green sharpie marker.  88/40.  112.  98%  36ET.
1429 - i’m sweating.  the patient seems colder.  danielle asks our pilot for the heat to be turned on.  let the barbeque begin. 
1430 - danielle wants low suction to see if anything comes out of the stomach, I hook it up and turn the unit on.  about 100 mL of blood streaked content appears.
1431 – we’re discussing back and forth about AMPLE and the code events preceding out contact with this patient.  danielle heard something about cerebral palsy as the chronic condition.  reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish to midrange 3mm bilaterally, neuromuscular blockade in place and seems adequate.
1432 – i’m trying to accurately visualize how much blood has seeped out of the back wound into our makeshift body fluid catch basin since lifting with little success.
1433 – 96/46.  106.  99%.  36ET.  we’re treading water.  i’m wondering what’s going on inside.  i’m thinking her spleen for sure.  she feels warmer.  she still has a radial pulse.
1434 – in goes another 50mcg of fentanyl iv push.  danielle fills out more paperwork in her illegible hybrid script
1435 – i’m fiddling with the ventilator upper/lower pressure limits so the alarm lights will stop blinking.
1436 – reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish 3mm bilaterally, neuromuscular blockade in place and seems adequate.  fluid bag #2 runs dry, and warmed NS bag #4 goes up in its place complete with green identifier.
1437 – i actually take a moment to look out the window for the first time since lift.  that lasts about 10 seconds.  almost time to put up blood unit #3.  monitor is cycling again for blood pressure…my IV line is backing up.
1438 – danielle sneezes loud enough to be heard without keying up.  i’m looking for a vapor cloud.  we make eye contact.  she smiles and goes back to her paperwork.  i’m grabbing blood unit #3.
1439 – 88/44.  110.  98%  36ET.  pilot is giving a position report to comms: lat/long, time to run, speed in knots, altitude.
1440 – blood unit #3 matched, spiked, recorded and stickered onto the run sheet.  fluid bags 3 & 4 are running well.  reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish 3mm bilaterally, neuromuscular blockade in place and seems adequate.  her core is definitely warmer.
1441 – i unbuckle with permission and reassess her lower extremities.  it’s very difficult to find a dorsalis pulse either side.  her legs are cold.  there is a decent puddle of blood between her legs.
1442 – the pilot clicks on and lets us know we’re about 10 minutes from our trauma center destination.  danielle reaches above her head and flips a switch to isolate our intercoms from the pilot and switches over to an 800 mHz frequency.  seconds later, she has a crystal clear connection with a trauma physician at our receiving hospital.
1443 - danielle gives a brief report.  we’re a little ahead of schedule with a strong tailwind and are doing close to 150 knots, about 7 minutes out from the triple pads.
1444 - i’m squeezing blood unit #3 in by hand.  88/40.  112.  97%.  34ET.
1445 – 50mcg fentanyl IV push.  6mg nimbex.  i look down, and there is a huge mess of medical waste everywhere but the biohazard bag we opened up.
1446 - reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils sluggish 3mm bilaterally, neuromuscular blockade in place and seems adequate.  lots of chatter between the pilot now and our international airport and downtown traffic.
1447 – pilot calls the crystal palaces in sight.  we’ll be on final shortly.  good thing, because I’m about to spontaneously combust with the heater going full blast and the windows closed.  blood unit #3 is in.
1448 – patient rechecked, equipment checked, we’re checked.  all set for landing, secure in the back.  we orbit once and turn into the wind.  eyes out.  sterile cabin.  i have blood unit #4 in hand.
1449 – beginning descent.  it never fails, but everything comes to a halt outside both towers.  it’s the unexplainable helicopter effect.  cars become intersection fixtures.  people stop walking in the middle of the street.  the seasonal outdoor hot dog vendor leaves the lid open on her cart and we inevitably blow cinders, grass clippings and errant jujyfruits into the warming hopper.  it could be pouring rain, fire or brimstone and people would still stop to watch.
1450 - doing the carnival ride thing again.  blood unit #4 matched, spiked, recorded and stickered onto the run sheet. up it goes.  90/52.  114.  98%.  36ET.  consolidating all existing lines into the cot under the blankets for easy unloading.
1451 – touchdown center pad.  reassessing:  a pale/cool/moist adult female SIGSW abdomen,  bleeding externally controlled/internally unknown, cap refill delayed, pupils midrange 3mm bilaterally, neuromuscular blockade in place and seems adequate.
1452 – danielle and me both want out, and our patient to be inside the trauma resuscitation bay ASAP.  throttles back to idle, flat pitch.  aircraft side doors slide open in tandem.  this reassures the general public that it is not an alien attack after all, and inexplicably people resume walking and cars begin driving around the medical campus.
1453 – clamshells open, monitor secured to cot, patient disconnected from vent, O2 and BVM attached.  hot offload.  helmets come off outside the main rotor arc with our backs turned.
1454 – enter trauma center.  interested looking, appropriately attired people milling in/around trauma pit #1.  enter trauma pit #1 with patient.  nearly 15 physicians, resident physicians, med students, RN’s, RT’s and techs descend upon us.  trauma service assumes care of the patient.

end story.

i work at a remote base, and it takes me about 90 minutes to commute from home to where my helicopter is hangared. along the way to my base, I pass no less than seven crosses. on the way home I pass five (four if I take the back road to stop for coffee first and get on the interstate at a different on-ramp).

they are different colors, shapes, sizes. some are ornate, some are plain. some have names and others are adorned with just a date. the only common denominator is that the ones I pass are all very well maintained year around.

last summer, I went to a scene flight mid-morning for a sport utility vehicle that had rolled over multiple times at high speed on the interstate. the requesting county agency reported that the driver had been thrown clear of their vehicle.

we pre-flighted, lifted, and made contact with the paramedic unit on the ground, which said they were on the side of the interstate. the incident commander let us know he had cleared a spot to land us in the westbound lanes of the interstate. within four minutes we were making our first orbit of the scene to recon the landing zone and size up the area for other hazards.

riding backwards, I looked out of the window down at the stretch of interstate about 500 feet below. from our nearly 20° circling attitude, it was almost as if I were staring straight down. a name inexplicably popped into my head as I scanned the activity below . . . fabyan.

we touched down, hot unloaded and walked with our stretcher and equipment across the center median into the eastbound lanes towards the ground EMS crew working on our patient along the right shoulder.

there, larger than life, was cross number two on my way home providing the backdrop for my about-to-be-inherited trauma patient. the tall, sturdy wooden cross appeared to have a good coat of white paint, stained almost to its armpits by the mud splatter of raindrop splash. A brilliant shock of salvia and bluebonnets waved indifferently in the wind at its feet.

letters woodburned and centered into the cross arms were in perfect gothic font and carefully painted black spelled out the name . . . fabyan.

I actually paused for a second to look around. I don’t really know what, or who, I was expecting to see. instead, I knelt down and started to assess the packaged patient. as report was being given into one of my ears, the names of each cross I passed each shift coming and going with a name began to whisper somewhere in the back of my mind. I looked up again. now there was a tangle of medical supply wrappers, cast-off tape and part of a bloodied cut-off tee shirt woven into the bluebonnet stalks.

I brushed aside the dramatic and indulgent thought that somehow a scene like this had played out five years earlier, sans cross, and like a flash we were back at the helicopter and loading the patient. seven minutes later we were spinning up and further scattering medical debris.

hours and then practically a day later, the cruel alarm spit me from my sleeping bag cocoon. I left after passing off report, opted for the coffee stop (thereby deliberately avoiding return trip cross number 2), and headed back home.

does history repeat itself? do we really pay attention to what those roadside crosses stand for or are they more often than not simply dismissed as a memorial by the living for the dead?  what visceral feelings, thoughts, superstitions and beliefs do these memorials evoke in each one of you?

incidentally, history doesn’t seem to repeat itself that I could find. my search of internet news stories and archives failed to uncover a story of a fatal accident occurring at the actual site of an existing roadside memorial.

I was internally horrified that in the middle of a high stress, focused situation, the impact of roadside memorials burned upon my psyche seems to be that I can list them in order by victim name from east to west and then west to east along my commute route.

our patient? had been up more than 24 hours driving across six states existing on caffeine and low calorie twinkies and just plain nodded off. never did find out what the olympic marathon driving event was for.  no seatbelt. lots of soft tissue and ortho trauma and eventually was okay.

welcome to my blog.

 
as if i had time for anything else, i’m shoehorning a blog into my life. certainly not because my thoughts are so vital, or i’m a sage of emergency medicine. i’m writing because i enjoy taking in other people’s blogs.

my mind is always running. i find myself wishing i could “pull the plug” long after i’ve laid down and willed myself to sleep, even at the point of exhaustion. i’m not a worrier (which maddens my wife to no end) but there is always something to think about…to research…to learn…to consider.

and simply not enough hours in the day to do it all.

some of the best condensed learning experiences, firsthand and unfiltered, are presented through blogs. individuals with real life experience invite us in for a closer view through their eyes.

we see “business as usual” conducted three vastly different ways in seattle, selma and st. petersburg. we learn how personal prejudices unconsciously affect professional practice. we witness work seeping subconsciously into our personal space. unlikely sources of inspiration pop up in the most routine tasks. cakewalks turn into broken eggs.

most of all, the often highly personal thoughts and random spoutings of bloggers that become organized into posts frequently resonate with me and provide the missing punctuation marks to stop my endlessly running mind.

i hope you will link. participate. share. re-post. and most of all, enjoy.

first, the opinions/thoughts/ramblings/manifestos expressed in this blog are mine and mine only. they do not necessarily reflect the values of either my current employer or former employers.

second, this is an adult blog and will contain graphic descriptions of medical procedures, strong language, a jaded sense of humor and potential political uncorrectness that some individuals will undoubtedly find objectionable or offensive. america is a wonderful place, and if you dislike or disagree with what has been posted here, you can move on –or– post a rebuttal comment which will be published in its entirety without redaction.

third, the author of this blog has changed the names, locations and circumstances of actual events (when invoked) to ensure no local, state or federal privacy laws will be violated. as a matter of fact, if you believe you recognize a certain incident or situation – relax…you don’t.

i went out of my way to make sure you couldn’t.