ALL AROUND HER WAS THE ROAR OF THE helicopter and the smell of her own lost blood. Fourteen-year-old Patricia Bowen focused her frightened eyes on the flight nurse crouched over her head. “Am I going to die?” she asked. Patricia had been stabbed twelve times and was bleeding from her neck, chest, abdomen, and hands. As the helicopter flew at 130 miles per hour toward Houston’s Hermann Hospital, nurse Georgie Brown grabbed IV’s and began pumping fluids into Patricia. “No, honey,” replied Georgie. She carefully locked eyes with her patient. “Hang in there. Don’t give up.”
Slightly more than half an hour earlier, Patricia had answered the door of her middle-class home amid tall pine trees in northwest Houston. A fifteen-year-old boy stood before her. He asked her for a cold drink. Reluctantly, she agreed. Once they were in the house, the boy grabbed her, held her to his chest, and slit her throat with a knife. Again and again he stabbed her. Twice she felt the knife rip into her chest. When she held up her hands to protect herself, he slashed her fingers. Then he fled through the front door. Patricia stumbled after him, collapsing on the front lawn. A neighbor ran over, took one look at Patricia’s bloodstained body, and telephoned 911 for help.
Georgie Brown’s pager went off with a high-pitched whine at 2:19 p.m. on December 10. Within five minutes, Georgie, paramedic Guy Stevenson, and pilot Taylor Jordan converged on the helipad of Hermann Hospital and were soon lifting off. In flight, Georgie and Guy checked their equipment, popped their fingers into rubber gloves, and listened to information via radio about Patricia’s condition from an Emergency Medical Service ground crew. What they heard from the para-medics wasn’t good. Patricia’s blood pressure was dangerously low, between fifty and sixty, and there were decreased breath sounds in her left lung. She was bleeding to death. Inside the helicopter, Georgie’s and Guy’s adrenaline levels soared like those of a couple of runners trapped behind the starting line. Nothing focuses the mind and heightens the physical senses as does the battle with death.
It took only sixteen minutes by air to reach Patricia. The helicopter floated over her neighborhood, dodging pine trees and electrical wires, until it came to rest in the middle of her street. Patricia was rolled on a stretcher through the rear of the helicopter, and soon she was en route to Hermann Hospital. A chorus of beepers signaled her arrival to a team of trauma surgeons, surgical and emergency room residents, respiratory therapists, nurses, and x-ray employees. Suddenly the room filled with all kinds of noise. The electric door swung open. Georgie and Guy rolled Patricia in; heavy machinery was being pushed around. Over the roar came the authoritative sound of Georgie’s voice: “I have here a fourteen-year-old white female who has been stabbed approximately twelve times.”
The trickiest part of the surgery was repairing two punctures near Patricia’s heart. Two surgeons worked side by side. One of them was Dr. James H. “Red” Duke, the director of emergency services and the medical director of Life Flight at Hermann Hospital whose health messages have been syndicated on television and have made him a celebrity. “The principle at work here is for everybody to hold their hosses,” said Duke, as he reached into Patricia’s chest, rolled her heart over, and then held his finger on a wound beneath her heart to stop the flow of blood. He looked like a highly skilled plumber plugging a leak. Dr. Neel Ware, the other trauma surgeon, stitched up a nearby hole. Together they worked on closing the other ten.
The next morning, Duke dropped by the intensive care unit. “How ya feelin’, Patricia?” he drawled. “Pretty good,” she replied. Duke peered at her through thick bifocals and twirled his heavy moustache. “That’s good, honey, because ya sure got a hell of an airing out yesterday.”
Patricia Bowen looked at Duke blankly. She had no idea how lucky she was to be alive. She was lucky to be among the 40 percent of Texans who have access to a 911 system. She was lucky to live near a fully staffed trauma hospital. Most of all, she was lucky to have gotten a ride on the $1.7 million helicopter that saved her life.
“IT’S AN ABSOLUTE TRAGEDY THAT THE PUBLIC continues to deny the presence of the epidemic called trauma,” fumed Red Duke. “We are in mass de-NI-al, and believe me, de-NI-al ain’t no river in Egypt.” Duke was seated near the coffeepot at the Life Flight offices at Hermann Hospital, haranguing on his favorite subject—the crisis of trauma-related injuries in Texas. To judge by the state budget, trauma doesn’t even exist. No state money goes to pay for treating trauma. By comparison, about $10 million of state and federal money is spent on AIDS. “Trauma in Texas is sort of like the elephant in the living room,” said Duke. “Everybody talks about the elephant, feeds it, and cleans up after it, but nobody really sees it or does anything about it.”
What has Duke worried is that trauma is the number one killer of people under 44. Not only are trauma injuries increasing, but the number of hospitals in which trauma patients can be treated is dwindling. So many Texas hospitals have closed that in effect we have a hub-and-spoke system of hospital care: Patients who were once treated near the scene of accidents now have to be airlifted to larger, hub hospitals in big cities.
Helicopters can make the difference in such cases. In suburban Austin a teenage driver loses control of his car and suffers a head injury, a broken pelvis, and a broken leg when his car rolls down an embankment. A helicopter arrives within a few minutes, paramedics place a tube down his wind-pipe so he can breathe, and half an hour after the accident, he is in a hospital and on an operating table. Flight paramedics and nurses call cases like this one “neat saves,” which not only create the mystique of flight crews as white knights—the A-Teams of emergency medicine, heroes driven by an internal need to intervene in life-and-death situations—but also demonstrate why helicopters are effective: They save time. A thirty-mile ambulance ride can take up to forty minutes, depending on traffic, while a helicopter travels the same distance in twelve to fifteen minutes.
Helicopters were first used for trauma in the Korean War, where the concept of the “golden hour”—the sixty minutes following a traumatic injury, in which the odds of saving a patient are highest—was first discovered. During World War II, casualty rates were 4 deaths per 100 soldiers wounded. In Korea that number was cut to 2.5 deaths per 100 wounded, with the help of helicopters that transported wounded soldiers to physicians within the golden hour. In Vietnam, when helicopters came into their glory, the casualty rate dropped further, to 1 death per 100 wounded.
In 1972, St. Anthony’s Hospital in Denver became the first hospital in the country to provide EMS helicopter service. Duke started the first medical helicopter program in Texas in 1976 because banker John S. Dunn donated $135,000 to Hermann Hospital to build a helipad. “I had no idea what I was getting into,” said Duke. “I just figured if I had a helipad, I better damn sure go out and find some helicopters.”
After Hermann and five other hospitals with helicopter programs published studies showing that critically injured patients transported by air stayed in hospitals longer than patients brought in by regular ambulance, the race was on to fly in paying patients. Helicopters became flying billboards for hospitals, and flight crews became celebrities, visiting local schools and making appearances on the television news. By the end of 1986, there were 150 helicopter programs operating nationwide, and five Texas cities were included.
The hospitals wanted the cheapest helicopters they could get and wanted them to fly as much as possible. Often that meant single-engine helicopters flown by a pilot working a 24-hour shift. Helicopter leasing companies saw EMS as the answer to the downturn in their off-shore drilling business and were eager to make any deal they could.
“The push to fly in those early days was enormous,” said Mike Phillips, who flew for Life Flight in the late seventies and now flies for Austin’s Brackenridge Hospital—based Star Flight. “The hospital would tell us: ‘Go or the patient will die,’ and the leasing contractors would tell us: ‘Fly or you don’t get paid.’ ” Accident rates started to climb. In 1982 alone, there were about 25 EMS helicopter accidents nationwide per 100,000 patients transferred. “Guys were dying all over,” said Phillips. “First-rate pilots were flying into wires, all sorts of crazy things. The reason was, they were so tired. In the early years, there were times I was so tired after work that I couldn’t drive home, but I’d been flying for twenty-four hours with a helicopter full of people.” Finally, in response to lawsuits and bad press, the Federal Aviation Administration in 1988 issued new regulations for EMS helicopters that established rest requirements for pilots, as well as increased safety procedures. Since then, most helicopter programs have gone to four pilots working 12-hour shifts, instead of two working 24-hour shifts. Moreover, pilots are now the final authority on when it’s safe to fly and when the helicopter stays put. The result has been fewer accidents. In 1990, there were none.
Today thirteen helicopter programs are operating in nine Texas cities. Of the state’s biggest cities, Houston, Dallas, San Antonio, Fort Worth, and Austin have helicopters, but El Paso and Corpus Christi do not. The other programs are in Lubbock, Beaumont, Tyler, and Galveston. Between them, they cover all of the state except the Trans-Pecos, South Texas, and the tip of the Panhandle. All of the helicopter programs except Austin’s, which is operated jointly by the city, the county, and city-owned Brackenridge Hospital, are driven by profit. A basic no-frills program costs about $750,000 a year to operate; Hermann’s Life Flight, the busiest one in the state, costs $4.5 million. In most cities, helicopters are used more than half the time to transfer patients from one hospital to another rather than to pick up victims.
“When we first started out, we were kinda making it up as we went along,” said Duke. “We’ve finally figured out how to safely use the helicopters for covering vast distances within the golden hour. Now if we could just teach people not to do dumb things to hurt themselves, we could call it quits.”
THE FIRST TIME I MET FLIGHT nurse Mindy Nichols, she told me a series of bizarre stories about patients she can’t forget. One was about a woman who had placed a turnip inside her vagina and forgotten about it. It was discovered when she called EMS suffering from abdominal pains; it had sprouted roots. These kinds of stories are endemic to the culture of emergency rooms.
Another flight nurse said that men on the edge of consciousness sometimes lose their inhibitions. “I had one guy who begged me to let him lick my fingers all the way to the hospital,” the nurse recalled. “I told him, ‘I don’t care how hurt you are, you can’t lick my fingers.’ ” In Houston I heard about a man who came in with a bottle of Brut cologne stuck where the sun does not shine.
What kind of people would consign themselves to this sort of work culture? Flight crews have the same sensibilities as firemen, police officers, and ground paramedics, with the added intensity of speed and flight. They are goal-oriented excitement addicts who are coolest in life-and-death situations.
When an EMS helicopter lifts off, three distinct worlds converge in 220 cubic feet of space: those of nurses, paramedics, and pilots. What attracts all three to EMS flying is autonomy—the chance to confront the unexpected and have the authority to act alone. “Out in the field, we don’t have time to telephone a doctor and say, ‘Mother, may I?’ ” said Dallas flight nurse Sandy Willis. “We just haul ass and do what needs to be done.” Flight paramedics are accustomed to working in the uncontrolled environment of the streets. What they like about flying is that in helicopters they get to do more invasive and complicated procedures than in regular ambulances. Pilots like flying helicopters because no mission is the same. “It’s a lot different than flying in Vietnam,” said Houston pilot Glenn Storey. “I haven’t been shot at lately, but I have landed in the middle of the freeway during rush hour.”
The competition for flight jobs is intense, even though flight nurses are paid no more than emergency room nurses, and flight paramedics earn no more than ground paramedics. A paramedic earns about $26,300 a year, while a flight nurse, who has a higher level of medical training, earns about $34,000. The wage difference has caused tension and turf battles in some programs, particularly in Austin. When Star Flight first started in 1985, the helicopter flew with two paramedics and a pilot, but no nurses. Today some paramedics continue to regard nurses as unnecessary. “What’s the difference between a helicopter and a flight nurse?” goes a joke popular in Austin paramedic circles. Answer: The helicopter eventually stops whining.
The gallows humor and the day-to-day grousing are ways of coping with the stress of the job. Not only do flight crews see horror and brutality on a daily basis, but they also confront the physical danger of flying. Houston flight nurse Rosie Waindel survived a crash in April 1989, when her helicopter’s tail rotor hit the Hermann Hospital parking garage on takeoff. All three members of the crew survived, but Rosie was in the hospital for one month. She couldn’t walk for two and a half months because of her injuries. Today she works with steel rods in her back. I asked her why she returned to flying. “I worked real hard to get this job,” she told me. “I wasn’t going to let anything take it from me.”
Red Duke’s theory is that flight crews are like all emergency room personnel: foolish crusaders who are addicted to cheating death. “They seek out these jobs because of who they are to begin with,” he said, “and then this environment we operate in keeps us all hooked.” The long hours create a group culture. Most nurses and paramedics work 12-hour or 24-hour shifts two or three times a week. The atmosphere in crew headquarters is jovial, even familial. In Dallas one pilot is called Papa Smurf. In Austin a blond paramedic is called Old Yeller. There are nicknames as well for types of trauma. “Good trauma” describes the most critically injured patients. Amputations are good trauma. So are multiple gunshot wounds, especially those involving unusual guns like Uzis. “Junk calls” are false alarms.
I experienced a junk call in late December when I flew with Star Flight. The call from the 911 police dispatcher came in at 5 p.m. All we knew was that two children were missing near a rain-swollen creek. I felt the rush of adrenaline as we lifted off from Brackenridge Hospital and floated over the state capitol. Beside me, Pauline Van Meurs, the paramedic, was sorting through rescue ropes while Lourdes Maier, the flight nurse, consulted a map and talked to the dispatcher by radio. I sat still in my seat, sinking inside myself to prepare for the sight of two injured, perhaps even dead, children. As we made our way north, I heard the voice of the dispatcher inside my helmet: “Cancel Star Flight 1.” The children had been found. They hadn’t been lost in the creek at all; they were visiting a friend’s house without their mother’s permission. “I hope they get a whippin’,” I was shocked to hear myself say.
I realized I was becoming what flight crews call a trauma junkie, one of those people who figure that if disaster is going to happen, it might as well happen on their shift. The worst part of any shift is the wait. Hours—sometimes whole days—pass between calls. When the weather is bad, as it was for days and nights on end in December, helicopters are grounded and injured people die. When fog rolls in, the helicopter is useless. In some programs, flight nurses help out in emergency rooms during slow times, but usually all three members of the crew sit and wait, trying to magically conjure up calls. Some eat dinner, believing the moment they take the first bite, a call will come in. Some start a good book. Others pop a movie in the VCR. In Austin a particular favorite is Dr. Strangelove. When the base commander, played by George C. Scott, rants about the Communists robbing us of “all our precious bodily fluids,” the waiting members of the crew enjoyed an insider’s laugh. For them, precious bodily fluids are not an abstract idea.
But I found out that the best way to provoke a call is to go to sleep.
WAKE UP!” SAID MINDY NICHOLS. “We’re going to Uvalde.” It was 12:30 a.m. and I was thirty minutes into an uneasy sleep on the floor of AirLife headquarters at Baptist Memorial Hospital in San Antonio. As we race-walked to the helicopter, Mindy explained that we were going after a 55-year-old Hispanic male suffering from kidney failure. This was exactly the kind of patient AirLife was meant to transport: Without the helicopter, he might not survive the seventy-mile ambulance ride from a spoke hospital in Uvalde to a hub hospital in San Antonio.
It took only a minute or two for pilot John Fluke, paramedic Eric Epley, Mindy, and me to get buckled into the Bell 412 and prepare for lift-off. The three of them were suddenly very serious, completely engrossed in the details of their work. As the helicopter flew first over freeways, then over dark pastureland, I felt the physical rush of power that comes from running toward, not away from, death.
Thirty-three minutes after we took off, the helicopter hovered over a grassy spot near the Uvalde hospital. By now it was just past one in the morning, and I was suprised to see about thirty EMS volunteers on the ground, lighting a landing area for the helicopter. I watched them brace themselves against the wind. All of them presumably had paying jobs to get up for the next morning, yet each had gotten out of bed in the middle of the night to do this work for free. I hurried off the helicopter to ask them why. “Just crazy,” replied one who had positioned himself near the helicopter’s side door. “But you never know when somebody in your own family is going to need this kind of help. If I help tonight, maybe somebody else will help out when it’s my turn.”
By then Mindy and Eric had hurried into the emergency room wearing their shiny blue fire-resistant flight suits and carrying two armloads of intensive-care equipment. They looked like the cavalry to the harried nurse who rushed toward them and said, “Thank heaven you’re here. You’re looking at the only pair of hands in the ER tonight.”
Mindy turned her attention to the patient. Pedro Alvarado was lying on a table, groaning. “Does he speak English?” asked Mindy. “Not much,” replied Pedro’s wife. Their 22-year-old son stepped forward. He was wearing a black gimme cap that read, “Till Death Do Us Part,” but no one seemed to notice the irony.
“It’s going to be cold, Pedro,” Eric said, as he wheeled Pedro out of the hospital into the night air. “Que paso?” asked Eric, but Pedro did not answer. By then he was unconscious. I had seen other paramedics around the state talking to unconscious patients. It’s a way of maintaining a human connection. Besides, most flight crews are aware of studies showing that even the unresponsive patients hear and remember what was said to them by emergency personnel. “I talk to all of them now,” one Austin paramedic told me, “especially the dead ones.”
Pedro was in danger of having a heart attack. Inside the helicopter, Eric hooked him up to a machine that monitored his heartbeat and the level of oxygen in the blood. It was eerie to watch Pedro’s heart register a beat on the tiny computer screen overhead. The rhythm of the beeps was all wrong. His body was tangled with IV’s, and his head was held still in a brace. His face was brutally moist—he seemed to be leaking from his eyes and mouth. Occasionally his eyes opened, and I looked inside to the forbidden world of fear and death.
The scene inside the helicopter was luminous. Eric and Mindy were detached and aloof, a couple of well-trained technocrats instinctively working at top speed. Twenty minutes into the flight, Pedro breathed easier. His heartbeat was still irregular, but his blood pressure stabilized. “He’s doing better,” said Eric.
Inside the intensive care unit at Humana Hospital in San Antonio, there were ten times the number of nurses and doctors we’d left behind in Uvalde. The now-familiar ritual began. Mindy gave her report while Humana’s team started their own round of tests. One of the nurses stroked Pedro’s arm while speaking to him in Spanish. The rhythm seemed to revive him. Pedro awoke briefly to complain of being cold.
He was going to make it. It was time to think about going to sleep. I asked Mindy how she copes with the highs and lows of her job, saving some lives and losing others. They all have their ways—some do t’ai chi, some bake bread, others try long-distance running—but not one of them likes to talk about it. “The way I do this job,” said Mindy finally, “is to be grateful for the ones we save.”