A Final Arc of Sky

Beacon Press

Chapter One

When I parked my car at ten minutes to nine that summer morning and dragged my helmet, flight bag, food, and laptop up the stairs at the southernmost of our four helicopter bases, the last dregs of predawn coolness still lingered in the air. I was in a good mood. I had just blasted the B-52's Cosmic Thing on my car stereo, playing my favorite tracks over and over like a five-year-old for the hour and a half it had taken me to commute to the base from home for a twenty-four-hour shift. The National Weather Service had predicted temperatures in the nineties, but the heat hadn't yet begun to shimmer off the helipad back behind the fire station where we were quartered.

The fire station is tucked into a rural corner of a medium-sized suburban city, next to a county airfield, and the landscape around it was cleared of its native forest a long time ago. It's as open as farmland in Kansas, dotted with Scotch broom, an invasive weed that is nevertheless lush with tiny yellow blooms each May. The sweep of the earth falls away to volcanic mountains in the distance, still snow-covered even in summer, and on my speed walks around the fire station for exercise I'd come to love it, in spite of the landfill that'spractically next door. I loved the light and space, the foothill feeling of the land as it runs imperceptibly up toward the mountains.

The day felt pregnant, though-that occupational precognition I've come to trust and dread. It's a feeling with a dart of fatalism in it, a blind, nonnegotiable foreknowledge, and I've learned the hard way that it's pretty accurate. Not 100 percent infallible, but up there. Whenever the feeling comes on me, I think of the animals who head to high ground before a tsunami, whose nervous systems seem to warn them of earthquakes and floods. Rats deserting a sinking ship.

It was also a Friday in high summer, so no shit, Sherlock, of course we'd be busy. We could look forward to office workers ordering margaritas at outside tables in the hot afternoon and driving home wasted in the dusk. Guys with huge guts and crap in their coronary arteries pushing their lawn mowers in the heat around their acre-and-a-half yards. Stoic eighty-year-old Scandinavians deciding it was time to climb their twenty-foot ladders and clean the old moss off their roofs.

Jason was my partner. We chatted with the off-going crew, lingering over our coffee in the sturdy, firehouse kitchen. Eventually we strolled out into the fine summer sunlight, across a short expanse of pavement, and under the main rotor to check the helicopter and our medical bags for completeness and readiness. Everything looked good. No blood splatters on anything, maybe just a couple of small things missing, and we replaced them. At the time, I had been a flight nurse for about three and a half years. Jason had just transferred from another base; I'd met him and talked to him at meetings, but we hadn't flown together before. He was our youngest flight nurse, about fifteen years younger than me, which is to say he was fifteen years younger than most of us, a thing he was teased about occasionally. He was short and compact, bespectacled, analytical and smart, calm. We finished our checklists and went into the office to fax our supply requests to the main base.

Jason put his feet up on the desk and said it was almost a year to the day since he'd started with our outfit. "My first flight," he said, chuckling, "was CPR in progress for thirty minutes in the aircraft."

"Ouch! Was it trauma?"

"Yup. A rollover on the freeway. It was ... stressful."

"Was CPR already in progress when you took over the care of the patient?"

"Yup."

"Hah! That is stressful, especially for a first flight," I said, picturing it and laughing a little. On your first-ever flight, the rush of foreign sensations-the vibration, the roar, the cramped quarters, the whizzing landscape-makes the simple act of strapping yourself in to the helicopter enough of a challenge.

"But to my mind it's not the most stressful situation," I added. "I mean, when you get trauma patients with CPR in progress, yes, it's an exercise in doing everything possible, but they're basically dead already. You can't hurt 'em."

At that point, I was thinking of a physician friend, my own gastroenterologist. I see him for gastroesophageal reflux-chronic heartburn, and who knows whether it's because of genetics, the two ten-pound babies I've borne that mashed my insides to a pulp, or this job. He told me once that when he'd first started out in medicine, he was scared to take care of really sick-critical-patients.

"But then I realized," he'd confided, grinning a little, "that they only get so sick, and then they die."

Yeah.

"The most stressful situation," I mused aloud to Jason, "is when they're lying there talking to you and then they code. The ones who roll back their eyes and die right there."

I can't remember if I mentioned to Jason that it was a situation that had never yet happened to me in flight, but it hadn't. And for all my years of experience on the ground and in the air, I didn't know how well I would acquit myself if it did.

I must have temporarily lost my mind, saying such a thing with that fatalism sitting like a stone in my stomach, with the twenty-four-hour day so early in gestation and our flight suits so clean, with the caffeine of the morning coffee still running in our veins. Saying such a thing on a Friday in summer.

Jason snorted. The harsh fluorescent light on the office ceiling flashed off his stylish little glasses, and I couldn't tell what he was thinking. It was probably something like Now she's cooked our goose. "Well, yeah," he said. "No question about it. That would be the worst."

It was early afternoon when the pager shrieked for the first flight of the day. We kicked off our sandals and zipped up our boots and our flight suits, and off we went to a small community hospital, a thirty-minute flight toward the coast, over open valleys and rivers winking like bottle caps in the hot noonday sun. Brad, our pilot, dropped the aircraft down light and easy onto the helipad, and Jason and I slid our stretcher, bags, and monitor out onto a gurney. We trucked the whole thing in through the emergency department door and up to the ICU on the second floor.

Our patient was Doug. He was forty-six years old, with esophageal cancer and an upper gastrointestinal hemorrhage, and we were transporting him to an oncology referral center, where they had more resources to deal with his problems. His esophagus, which transports food from the mouth to the stomach, had a large tumor on it, and he had been receiving chemotherapy and radiation to debulk it, to shrink it enough so that a surgeon would have a shot at removing it. Apparently, a blood vessel in that region had eroded earlier that morning. It had gouted large amounts of blood.

A hematocrit measures the percentage of the volume of red blood cells in the total volume of blood and is used as quick guide to how much blood has been lost and how well it's being replaced. A normal crit is about 40 percent. After he started vomiting blood, Doug had an initial crit of 17 percent. He had received five units of packed red blood cells and other blood products since that measurement had been taken, but there hadn't been a repeat crit. He had not vomited any blood recently, and he came with a tube that had been surgically placed in his stomach through his abdominal wall-there wasn't much output from that, either. We could assume that the bleeding vessel had clotted off. For the moment.

He had other problems too. A collection of straw-colored fluid between his left lung and the pleura, the covering around his lung: a pleural effusion caused by impaired lymphatic drainage secondary, to his tumor. The ICU staff had just drained 520cc-more than two cups, quite a bit. I hoped it wouldn't reaccumulate too quickly. He also had a small pneumothorax of the right lung. This was a collection of air between the pleura and the lung. The problem for us was Boyle's law: air expands at altitude, and aloft a small pneumothorax can become a large pneumothorax, collapsing the lung and, if it's big enough, compressing the heart and the great vessels that transport blood into and out of the heart. In an ICU, a big pneumo would buy the patient a chest tube so air could drain continuously. At altitude, if it became a problem, Jason and I would temporarily treat the pneumo with a flutter valve-a large-bore, sharp steel needle that had been sterilized with a disposable-glove finger rubber-banded to the hub. The glove finger acts as a one-way valve. We'd stick the needle through his chest wall, into the space between the second and third rib, and it would allow air to escape.

And there at hell's heart, Doug just looked end-stage. Esophageal cancer tends to be advanced by the time it announces itself. He was skin and bones, shadowed hollows instead of mounded pink flesh, a victim of his own personal holocaust. His hair and eyes were brown, but he was so ashen an Impressionist would paint him in shades of gray.

He was, however, awake and alert, polite and pleasant, exhibiting the prosaic courage of an ordinary person in an extraordinary situation, the sort of courage that redeems the human race over and over again, a million times a day. He had three or four children visiting him, a gaggle of pretty girls in their preteens and early teens, their midriffs showing, acid-washed jeans low on their slim hips. As I worked fast to get my equipment on him, I heard him kiss them good-bye, heard them tell him they loved him, heard him say he'd see them later.

Jason had finished taking a report from the ICU doc out at the nurses' station desk. We were almost ready to go. I took stock of Doug's vital signs on the monitor over his bed. He had a decent blood pressure for the moment and a low-normal oxygen saturation, but his heart rate and respiratory rate were high, and it was difficult to tell exactly why. It was likely he needed more blood products. His pleural effusion might have been starting to reaccumulate, or his pneumo might have started to enlarge.

I wondered if we should place a tube in his trachea before transporting. This would allow us to breathe for him, to take control of his aimway and maximize his oxygenation and ventilation. The reasons for doing it were obvious-he was skating close to the edge, on the verge of decompensating. It's easier to intubate in the ICU with five people to help than in the aircraft, and it'd be one fewer set of problems for us to deal with if we ran into trouble en route.

But intubation would take time and delay transport. And even with the muscle relaxants and sedation that are used to accomplish the procedure in a conscious patient, it can cause a spike in blood pressure, a spike that could blow a barely formed clot off an esophageal blood vessel. The question for us was whether Doug's tenuous situation would maintain itself for the hour that it would take to reach the large referral center. It was a judgment call.

"His respiratory rate is twenty-eight," I murmured to Jason. Normal is about twelve. I was on the fence about intubation, and I could see that Jason was too. I shrugged, to let him know I was equivocal. He waggled his head from side to side. We both sneaked a glance at Doug. He was still hugging his girls and chatting with the ICU nurse. Jason and I wrinkled our noses, shook our heads. Without a word passing between us, we decided we'd just get out of Dodge.

Probably thinking of the esophageal cancer at the base of this mess, an illness that was likely to be terminal, Jason turned to Doug and surprised me by asking if he had an advance directive, a living will.

Doug said no, he didn't.

The question is certainly reasonable in and of itself, but in our practice setting, if they're calling for an emergency helicopter transport, then the patient is usually not ready to die. We can assume he's not willing to go out without some fireworks. But Jason persisted. "If something happens during the flight, do you want us to put a tube in and breathe for you? Do you want us to give you drugs?"

"Yes," Doug said. He took the questions in stride. "Do everything."

The exchange was a model of clarity.

We slid him onto the gurney, wrapped him up in our bright yellow pack, trundled out to the helipad. As we were loading Doug into the cramped confines of the cabin, he complained of stomach pain. I promised him morphine once we got settled and pushed the button on our monitor to cycle a blood pressure. The digital number clicked onto the screen-80 systolic. I felt a little worm of worry creep up the back of my neck; I increased his IV fluids as we stowed everything. I told him his blood pressure was a little low, that I was giving him a fluid bolus, that his pressure needed to improve and stay improved before I could give him anything for pain but that I'd do it as soon as I could. Narcotics drop blood pressure.

Jason settled into his right-side, aft-facing seat. I strapped myself in, facing forward on the left. The next blood pressure, gotten as we were taking off, was 110 systolic. Better. I began to breathe a little easier. The emerald valley floor slid by beneath us under a white-hot sky. Doug lay on the stretcher with his head just above and in front of me, the back of the stretcher ratcheted up at a thirty-degree angle. He seemed to be looking at the scenery.

Five minutes into the flight, forty minutes out from the receiving hospital, he started spitting at my window, saliva mixed with streaks of blood. It rolled down the Plexiglas. I reached up with the Yankauer, a rigid suction device, and tried without much success to help him use it. He wasn't paying attention. Splu-ee. He continued to spit at my window as if I weren't there. I lifted one of the earmuffs we had placed on him to protect him from the roar of the engines and asked him if he was okay. He nodded yes. He wasn't retching, just spitting.

But then he urped up a glob of frank blood (That was our clot, my mind whispered) that landed on the floor next to my left boot, and before another thought could cross my mind, he was unresponsive and apparently seizing. His jaw was clenched, his eyes were closed and twitching (rolled back his eyes), and he started to spout blood out of his nose and mouth. It was thin, watery blood, as if the hematocrit was low. Very low.

He still had a blood pressure, 140 systolic. A heart rate in the 140s as well-high, his heart pounding away, trying to make too few blood cells do all the work. But the shit was hitting the fan, no question about it. We increased his IV fluid again, and Jason wrapped a pressure bag around the single unit of packed red blood cells that the sending hospital had been able to give us. They had used most of their stock of red cells on Doug earlier in the day. Jason and I knew we had to intubate him, and while we were pawing at the respiratory bag and pulling out the supplies, his heart rate and oxygen saturation dropped into the sixties. This is one step away from dying outright.

"Fuck," I said, and Jason agreed.

Our pilot asked what was happening. He had been a paramedic, and he could hear our terse exchanges over the intercom.

"He's going down the tubes," I said. "This is going to suck. We're both out of our seat belts." We let the pilot know when we're unrestrained, so he can avoid unexpected maneuvers.

"Got it." He asked us if we wanted to divert to the trauma center. This was a good idea. The trauma center had a helipad; it was ten minutes closer. The trauma center was also a little more geared up for this sort of emergency.

Using a mask and bag to breathe for Doug, we bagged both his heart rate and oxygen saturations up to near normal levels. The nurse sitting on the left side in our aircraft is in the airway-management seat. A successful intubation is all about getting a good view of the vocal cords, and the ergonomics for intubation are a little better from the left.

That meant me. Making a mental and physical effort to keep tabs on my equipment, which wanted to scatter all over the floor, I edged over from the left seat to the middle of the cabin while Jason continued to ventilate with the bag and mask. I wedged myself between the monitor/defibrillator and the head of the stretcher. My butt rested on the monitor screen. As makeshift and uncontrolled as it sounds, this position worked pretty well for me. It was probably ninety or even a hundred degrees in the helicopter, and I'm sure I was sweating buckets, but I don't remember my body at all. I slid the laryngoscope into Doug's mouth with my left hand. The scope has a blade to keep the tongue out of the way, and a bright light at the end of the blade so you can see what you're doing. Blood kept welling up into his airway from his esophagus, and I had to suction him several times with my right hand before I got a clear view of his vocal cords. But there they were, pearly white. I had less than a second to drop the suction catheter, pick up the ET tube, and slide the tube through the cords before blood fouled the field again. But he had stopped seizing, and he was anatomically easy to intubate. I knew I was in. Even under those circumstances, there was a subintellectual pleasure in it.

(Continues...)

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Excerpted from A Final Arc of Sky by Jennifer Culkin Copyright © 2009 by Jennifer Culkin. Excerpted by permission.
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