A
Shift in the Life — The Ongoing Story of a Critical Care
Nurse
by Matthew Nathan Castens, RN
“Chest
Pain at 30,000 Feet”
My days
off are never actually days off. When I’m not working
at my "real" job in the Cardiovascular ICU recovering patients
from open heart surgery, I am on call as a flight nurse. Flight
nurses are registered nurses with several years of critical
care under their belts. Most flight nurses work on helicopters
doing scene responses to major traumas or transporting critical
patients between hospitals. Some of us work on special air-ambulance
planes transporting patients longer distances than can be
reached by chopper.
I work
on airplanes. The company I work for charters KingAir 200
twin-engine turboprobs for interstate transports. Usually
we fly around the Midwest carrying critical patients between
hospitals. Our planes are specially fitted with a small ICU
bed and we have all of the monitors, IV pumps and medications
that an ICU or emergency department needs -- just in smaller
supply.
On this
particular sunny day, I received a page to fly from Minneapolis,
where I live, to Fargo, North Dakota. We were to pick up a
patient to be flown to the VA Medical Center in Minneapolis
where he would receive and angiogram and possibly an angioplasty
or open-heart surgery. This was a fairly emergent case because
the Fargo hospital wasn't able to get rid of his chest pain
with medications.
I was
excited about going. It had been a while since I had been
up in the air. I met my coworker Jesse (all names have been
changed), who would be the other RN on the flight. (Jesse
and I also work together at the hospital, so I knew we'd have
a good time.) All flights have medical crews of at least two
people: usually an RN and paramedic, but sometimes two RNs,
or an RN and EMT.
We loaded
up our gear and had the wheels up right on schedule. I had
taken the flight to Fargo many times and knew it like the
back of my hand. It was a quick, easy one-hour flight. When
we met the ambulance on the tarmac, I got the bed and plane
ready while Jesse went to assess the patient, Tony. He was
still having chest pain. Normally we would not fly a patient
with active chest pain, but since this was previously known
and he was flying to Minneapolis because of it, this was not
a problem. We was on a nitroglycerine IV drip to help control
the pain and we could give him all the morphine we needed
to also.
Nitroglycerine
(nitro) works by dilating the blood vessels of the body so
the heart doesn't have as much volume to pump -- if it doesn't
have as much volume to move, it uses less oxygen and helps
prevent too much damage. Morphine works in the same way with
the added benefits of direct pain control and relaxation.
The nitro
was at a fairly low dose -- about 30 micrograms per minute
-- so Jesse started to titrate it up. She also gave Tony some
morphine. As we taxied for takeoff, I mentioned to the pilots
that he was having chest pain and that they should try to
keep the cabin altitude as "low" as possible. When a person
flies, the increase of altitude lowers the air pressure and
the availability of oxygen. Airplane cabins are pressurized
to maintain comfort and oxygen supply. Even on jetliners,
the cabin altitude can only be kept set at a certain altitude
and if that altitude is too high, the lack of oxygen supply
will aggravate any preexisting cardiac problems, like Tony’s.
The pilots
asked if it was OK to keep the cabin altitude at 5,000 feet.
I knew that it was still too high to prevent chest pain, but
the only way to lower the cabin altitude further would be
to decrease the plane's altitude. If we decreased the plane's
altitude then the flight would be longer, thus preventing
Tony from receiving fast medical intervention. We decided
that a plane altitude of 30,000 feet and a cabin altitude
of 5,000 feet would be the best for the patient and we took
off.
Just before
leaving the ground I phoned ahead to the ambulance dispatch
in Minneapolis to give them our ETA. They would send a critical
care ambulance with an RN on board to transport Tony to the
hospital. The critical care ambulances are set up like our
plane -- a mobile intensive care unit.
As we
climbed, Tony's chest pain got worse. His nitro drip was up
to 100 micrograms (mics, or mcg), which is about midrange
dose. We has also given him a total of about 10 mg of morphine
to keep his pain tolerable. Jesse and I were concerned, but
we knew everything was still under control. Tony’s heart
rhythm looked fine and his blood pressure, although still
higher than we would have liked, was stable.
All of
a sudden, after what seemed like only five minutes in flight
we heard the pilots confirm and start their descent! Jesse
looked at her watch -- we had only been flying for 30 minutes!
The tailwind at 30,000 feet was strong enough to cut the flight
in half. This posed a small problem: the ambulance wouldn't
be meeting us at the airport for half-an-hour, and Tony needed
to get to the hospital as fast as possible. The tailwind worked
in his favor, but it would be a moot point if there was no
one to pick him up.
I asked
the pilot to radio ahead to dispatch to see if they could
get the ambulance to the airport faster. They talked for a
while and relayed the message. Unfortunately, the ambulance
was on another run and wouldn't be available for 30 minutes.
Although Jesse and I could manage Tony and his pain just fine
for that amount of time, I would have rather used the extra
time available to prevent Tony's heart from becoming too damaged.
I spoke
to the pilot, "Tell them the patient is having chest pain,
and if they can get the ambulance here any faster, that would
be great!" The pilot relayed the message.
What
no one on the plane knew at the time was this: when dispatch
receives a call from a plane that a person is having chest
pain they must immediately activate the 9-1-1 system; the
scheduled ambulance was canceled and all pandemonium broke
loose.
We landed
on the tarmac ahead of schedule and taxied to our hanger.
The local fire department had been running a practice burn
across the road and had two utility trucks on the runway with
EMTs at the ready, the local police and sheriff each had a
cruiser nearby with officers anxious to help. Everyone had
their respective medical equipment in hand and all of the
lights were flashing. We didn't know what to think.
As we
opened the door, an EMT and police officer ran up the stairs.
They stopped when they got inside and looked around...
"This is an air-ambulance!"
"Yes, it is," we replied.
"You're nurses?"; “Yup”.
"Well, heck, you don't need us -- what are we here for?"
After
some discussion, we discovered what the communication breakdown
actually led to. The local ambulance with its paramedics came
screaming up with lights and sirens. Unfortunately, as I mentioned
before, the scheduled ambulance had been canceled in favor
of 9-1-1. The paramedics were more than willing to transport
Tony to the VA hospital, but we were left in a quandary. They
only had two paramedics (no nurses), and didn't have an IV
pump which Tony needed for the nitro drip. As they kept telling
us, they were 9-1-1 paramedics, not critical care transport
nurses.
At that
point, I didn't care. Tony needed to get to the hospital as
soon as possible. As Jesse got Tony ready for his ride, I
went over everything I could with the paramedics. They had
protocols in place for a patient with active chest pain and
morphine. I stopped the nitro IV and instructed them to use
nitroglycerin mouth spray constantly to keep Tony's pain and
blood pressure under control. The police and fire packed up
and left the scene.
We heard
later that Tony made it to the hospital just fine. They took
him directly for his angioplasty and he had open-heart surgery
a couple of days later. Jesse and I learned to never mention
our patient's condition to medical dispatch unless we need
9-1-1.
From now
on we'll just say we need the ambulance schedule to be altered
for the patient's sake.
In the
end, it all worked out. Jesse and I smile about it to this
day.
