Flight Nurses Practice Critical Care in the Air
Monday January 15, 2007
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For Mark Jonas, RN, CFRN, EMT, the ability to provide critical care in the air is invaluable in Alaska, where many residents live in remote villages.
(John T. Callahan)
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Bevin and another RN arrived via helicopter and gave her large and repeated doses of fentanyl for pain. It was clear to them that she was not going to survive. The middle-aged woman looked at least 80% burned. This left them with a critical decision: Should they intubate immediately to preserve her airway or hold off until she arrived at the hospital? If they acted immediately, they’d need to sedate her, which would eliminate her ability to talk. She did not show signs of smoke inhalation, and they knew this meant she could breathe independently for the flight.
“We held off on the automatic response to intubate as we thought about the bigger picture,” Bevin says. “If we could give her the opportunity to pass on information about her relatives, the family could get involved much sooner. We also wanted to give her the chance to have a say in how she spent her final hours.”
Although charged situations like this may seem stressful, Bevin thrives in a nursing specialty that requires the flight team to make crucial decisions quickly and sometimes independently. Three flight nurses — Bevin, Mark Jonas from Alaska, and neonatal nurse Marianne Wilson — agreed to share with NurseWeek the realities of providing critical care at high altitude. Their candid interviews reveal a mix of both the difficulty and satisfaction they face on a daily basis.
“It’s a job where there is a lot of autonomy, and as a nurse you are making major decisions,” Bevin says. “I’m always interested in finding out the extent of the injuries in a trauma patient once they’ve been X-rayed and CT scanned, so I can see how close our clinical assessment was in the field.”
Initially, Stanford Life Flight had an MD and an RN on each helicopter flight, but in 1992 the program switched to having two RNs onboard. Nurses who apply must have a minimum of five years of RN experience, including two years in an ICU and two years in an ER. The majority of the flights are to airlift patients from an ICU or emergency department to a hospital that offers a higher level of care, such as Stanford. In these cases, Bevin is trained to offer Stanford’s care as soon as he’s at the bedside.
For instance, in a case of an aortic dissection, the team typically titrates two powerful drugs to decrease the patient’s blood pressure. An external blood pressure monitor isn’t accurate enough, so they insert an arterial line to get a beat-by-beat readout. The crew’s goal is to get the patient’s blood pressure within the range needed by the surgeon as soon as possible after they make patient contact. The mortality rate increases by 2-3% every hour if the blood pressure is left untreated.
When he’s not transferring patients between hospitals, Bevin is usually responding to a scene call. Automobile and motorcycle accidents are the most common types of scene calls, but he’s also seen people who were injured in recreational or industrial accidents. One time he arrived to help a man who had fallen off an all-terrain vehicle in the hills of Santa Clara County, Calif. The man had ripped the tendons and cartilage in his knee, and Bevin was shocked to see that the man’s leg had contorted such that his ankle was side-by-side with his hip.
“He was screaming in agony because he’d been up there for 40 minutes because people had to drive down the hills to get to a phone,” Bevin recalls. “I placed an IV and gave him pain medication immediately and also on the flight to the trauma center. By the time he was down to the ED he was joking.”
“It’s not easy to see another human being suffering,” Bevin admits. “And of course we have some means to lessen the suffering, but when you see it over and over again, it impinges on your psyche.”
The hardest calls for him are burn cases and when children are in pain.
“Even though I don’t have children, I find a child in pain to be more emotionally difficult,” Bevin says. “An adult can rationalize why they are in pain. To children it is just pain and they do not have a good understanding about why. That is always difficult for any first responder. Part of the way I deal is that when I walk out of the hospital, I wash the day’s events out of my memory.”
And luckily the majority of his airlifted patients survive. “You have enough good outcomes to keep you going,” he says. “If I didn’t, I couldn’t do this job.”
And while flight nursing may seem like a glamorous job spiked with adrenaline, Bevin says they have their share of mundane chores. They are expected to inspect all the equipment on the aircraft at the beginning of every shift, clean the patient area after every flight, order supplies and restock their supply rooms. Another time-consuming task is stripping the rear cabin of the helicopter, scrubbing all the surfaces and then replacing the interior. At times, flight nurses are also expected to help out in the hospital’s ED and surgical ICU.
At least half of Jonas’ patients are people who call in with symptoms of a heart attack. Other reasons for airlifting include industrial accidents, premature births, or recreational accidents. Jonas works two 24-hour shifts per week, and when an air transport is needed, he partners with another RN, a nurse practitioner, or a paramedic on the flight. His partner depends on the condition of the patient and who is on duty when the call comes in. If the patient is within 150 miles of one of LifeGuard’s bases, then the team takes a helicopter. Fixed wing aircraft — which require a runway to land — are reserved for longer flights.
“You think it will take an hour and with bad weather it can end up taking many hours,” Jonas says. “The man ended up getting sicker and sicker.”
The flight team intubated and ventilated the man, gave him antibiotics, and managed his blood pressure with medication. Jonas later learned that the man did not survive.
The extreme cold, the long flights, and the confines of an aircraft make for tough working conditions, but Jonas sees this as a challenge rather than a frustration.
“The physical conditions we work in can be difficult,” he says. “We’ve had it so cold that we need to make sure IV lines don’t freeze as we’re transporting someone from the ambulance to the plane. It can be 20 below.”
His love of physical challenges surfaced in his former career as a guide for river, backpacking, and skiing trips. Though he enjoyed guiding, the seasonal work wasn’t enough to pay the bills. He decided to earn his nursing degree and worked as a nurse for seven years at Providence Alaska Medical Center. When an opening in flight nursing became available, he decided to apply.
His mountaineering background is particularly helpful when LifeGuard gets calls for people on Mt. McKinley.
“I know the glaciers and the passes because I’ve climbed them,” he says. “I rely on those skills quite a bit. Most of the flights to McKinley are people who have altitude problems like pulmonary edema or cerebral edema, and they are often pretty healthy people. They usually do really well.”
Babies who fly with AIRescue International usually need to be transferred to a hospital with a higher level of care, or they need to be flown back home a long distance. Wilson is in charge of putting a team together based on the patient’s condition.
“I will talk to the bedside nurse and the physician to find out what is really going on,” she says. “I’ll find out if the patient is on a ventilator, what the settings are, the IV fluids, the vital signs, and review the lab report, medications, and patient summary.”
Even with the best preparations, she still has to be prepared for the unexpected. Because fixed wing planes must land at airports and not hospitals, the patients are moved to an ambulance before and after the flight. One time she was caring for a 1.2-kilo baby who needed to be flown from Louisiana to Stanford for heart surgery. The ambulance ride was hard on the fragile preemie.
“She was close to dying, so we had a conference call with the neonatal doctors at AIRescue and Stanford and changed her care over the phone,” Wilson recalls. “We maximized the amount of oxygen and totally sedated her so she wasn’t moving to use up energy, and we adjusted her medication. We did all of that in the airplane prior to leaving.”
Luckily the adjustments improved the baby’s condition and she did well on the five-hour flight. The heart surgery was successful and the infant flew home two weeks later for the continuation of care.
In some cases Wilson will bring her nursing expertise onto a commercial airplane. Recently she accompanied parents of a premature baby who was born in Palo Alto while they were on vacation. The couple was from Hong Kong, and the baby girl was born at 31 weeks. The baby was discharged at 35 weeks, and Wilson flew with them to monitor the infant’s oxygen saturation and heart rate on the long trip home.
Wilson’s work as a flight nurse has taken her to countries throughout the world, including Romania, New Zealand, Guam, Singapore, and Mexico.
Although Wilson now works for a private company, she trained as a flight nurse at Stanford University Medical Center in the 1970s in neonatal/pediatric critical care, transport medicine, and safety. The fixed wing transport instructor piqued her interest in that form of flight nursing.
“We had to learn about things like the cabin pressure and different aircraft configurations, and how you have to plan for working at high altitude because it affects the patient and the crew,” she says. “I found this to be really interesting.”
Although she enjoys the relaxing hum of the plane, the fixed wing flights are often long and fatiguing, especially as she spends hours trying to care for miniature patients in a cramped space.
But for Wilson, the lengthy flights also open the door to the best parts of her job.
“I enjoy the intense focus it takes to care for the patient from point A to B,” she says. “It’s hard work because we take on difficult challenges, but it makes you feel good when you’ve been able to help a family. It’s appreciated by everyone involved.”
Heather Stringer is a freelance writer for NurseWeek. To comment on this story, send e-mail to editormtw@nurseweek.com.
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