Air Medical Resource Management Thoughts

Archive for March, 2018

Stress at a Critical Moment for an HAA Pilot

A pilot’s perspective of a patient’s medical emergency during a critical aspect of flight.

Not long ago I was on duty as the pilot for a helicopter air ambulance at a traditional program, so as the pilot I work for a part 135 helicopter operator and the medical crew works for the hospital we have a contract with.  We received what sounded like a rather routine call to a hospital about 50 minutes away.  The flight north was pretty typical for a crew that has worked together for quite a while.  The nurse/paramedic and I have worked together for over 10 years and the paramedic has been with us for about 6 months but worked on ground ambulances for our program longer than that and is also an RN  working in the local ER when not on flights.  The weather was clear, about 25 deg F and the winds were gusty with a little turbulence out of the south east as opposed to the prevailing northwest winds we see most often.  I knew that the return flight would be longer and rougher than usual due to the winds.

The trip back from my perspective was fairly routine again if watching the fuel flow and confirming I would be landing with the expected amount of fuel on board was considered routine.  Watching airspeed and arrival times on a windy turbulent day is always interesting.  Turns out I landed exactly as expected.  59 minutes after takeoff, and with 35 minutes of fuel, but enroute the GPS was giving me everything but an accurate enroute time.  Quite often I was watching the enroute time on the GPS increasing instead of decreasing due to turbulence and changing winds aloft.  Changing from lake effect winds near Lake Superior to the inland winds, 100 miles south is always interesting.  I am often accused of finding headwinds in both direction.

Enroute patient care was fairly normal as I listened to the med crew ask the patient where his pain level was at, did he feel nauseous, I felt bad about the turbulence, etc.  I was surprised with some of the answers from the patient as he often said the pain was a 10 out of 10 but he did not sound like he was in that much pain.  He also seemed to not be in too much distress from nausea despite the turbulence.  I was under the impression that he was over stating his pain number.  As we got closer to the receiving hospital the crew radioed in the patient info and asked for a hot off load.  I informed them that we would be landing to the east due to winds in the teens and gusting from that direction.  This direction meant that I would be landing facing away from the crew waiting on the ground for us and require them to circle around the front of the helicopter to unload the patient.  We have done this before so not a problem in and of itself just required more vigilance and was the original plan.  This was also our primary hospital and the ground help have done this before so not a show stopper.  Another option that I have done in the past when doing a hot unload with ground help was to make my approach into the wind but then do a 180o pedal turn putting the tail into the wind before setting down but allowing for a safer operation on the helipad.  This also meant we would be getting exhaust fumes in the cockpit on shutdown and startup. Something we tried not to do too often.

About 3 minutes out everything changed from a somewhat routine monitoring and administering of pain meds to #@#^*%#*@.      It started with the med crew turning on the patient’s mic and I heard a very desperate “I have to puke”, followed by movement in the back as I suspect the crew were getting an air sickness bag to him. Turned out to be two bags at least but I remember them asking him if he needed the bag anymore and he said no.  It sounded like the crisis was over.

Then it got even more intense when I heard, V-fib, we might have to shock him.  I can’t tell you much of the medical problem but what came next was a huge increase in stress.  One of the crew called for shocking the patient, Charge, Clear, shock, another called the hospital to tell them that we were charging and then shocking.  For this crewmember who I have flown with for over 10 years, this was not a normal call and his voice got significantly more excited, he was talking a lot faster and clipped the end of his sentence off. The reply from the hospital I remember was, in comparison, an amazingly calm, “I’ll tell the doctor.” There was an unreal feel to that short conversation, then the other crew member did the same thing with the same results when they shocked him again.

“Sir, Are you OK? Can you hear me? need to shock him again, Ken (me the pilot) stay clear of the patient, Clear, Shock”, feet jump, BEEEPWhat was that? That’s in my headset!  BEEP! What did that shock do to the helicopter, “Clear”, feet jump, coming over the back of the ridgeline into the hospital, BEEP, “Caution Terrain”, “Sir, Are you OK? Can you hear me?  Tell me your name”, BEEP, Instruments are fine, what is that noise?  Slow down, Relax, everything is OK, BEEP, what is that? Normal approach, good approach, “Caution terrain”, “warning obstacle”.  Good approach, BEEP, ignore, over the pad, “turning tail to right, landing” ground crew is here, a little tail wind but expected, down and safe. Idle, “your clear to get out”.  “Stay with us, we are on the ground and will get you to the cath lab shortly”.  I got him here.  But is he alive?

I will say that those last few minutes the collective stress level in that helicopter was amazingly high.  Dealing with a dying man, making radio calls, staying clear as they shocked him, a nonstandard approach because winds were not prevailing, monitoring fuel, obstacles and buildings on the approach path, a crew that was too busy with the patient to provide any assistance like normal, all added to an increase in stress.  There was a moment on final I had to actually talk to myself and I remember telling myself to just relax and make the approach.  Ignore the rest.  Ignore the Beeps, ignore the obstacle warnings since I did not have another hand to silence it at that point.  I was aware of all the things that were increasing the stress in the cockpit and with just a thought, relax and ignore it, I was back in control.

It was obvious what was increasing the stress level of the medical crew, It was very different but not surprising.  I thought the higher pitch and stressed call to the ER was interesting and a little humorous.  It was something I could give them a hard time about once we got the patient to the hospital.  I could tell that my stress level was elevated also simply by being there listening to them.  Then it went even higher with the BEEEEEEPS! This came as a monotone beep that was regular and since it was through my headset, and therefore not a medical device, I became distracted as I sought to determine what it was.  What did they do to my helicopter when they shocked the patient?  For a critical 20-30 seconds I was on personal autopilot as I started the descent down the back side of a small ridge into the helipad.  Luckily it was our primary hospital and although it was not normal to land from this direction it was also something I have done often enough in the past to know where to come over the ridge and start my descending turn to final and the helipad.  It was after I was on short final for the approach that I remember talking to myself to calm down.  I also made the decision to turn the aircraft tail to the wind.  This was not the plan but it was something I could do easy enough to ensure additional safety on the ground while they were unloading a patient they might have to do CPR on.  When they came back to the aircraft I was informed that the patient was still alive in the cath lab with severe blockage.  What a flight!  We talked about it then as we put a new liner on the cot and wiped down everything.  That was when I found out that what that BEEP was. “So did you guys have the tone in your headset too?”  “Yea that was the Michigan 800 mghz radio, we were out of range”.

“You’ve got to be kidding!”