Q&A with Janice Hudson
Emergency flight nursing is a gruesome and emotionally draining job that is only boring when waiting for the next call. Then comes the adrenaline rush of racing through the air to a scene, the pain of working over a dying child, the exhilaration of saving a life, and the fatigue from long hours without sleep. In this new and expanded edition of Trauma Junkie: Memoirs of an Emergency Flight Nurse, author Janice Hudson vividly recreates her 10 years with California Shock/Trauma Air Rescue (CALSTAR), and updates readers on how she and her colleagues have fared since the first edition of the book was published in 2001. Soon after the first edition was released, Hudson was diagnosed with cancer and then multiple sclerosis, which ultimately forced her to give up the job she loved. Trauma Junkie: Memoirs of an Emergency Flight Nurse: Updated and Expanded is available in paperback from Firefly Books.
You started flying in 1987, but you had been a nurse before that.
I started out as an open-heart nurse, but when my husband, Mark, and I got engaged, we didn't think it was a good idea to both work in the same place, so I transferred to the ER. That's where I met my friend Dana, who got me the job on a helicopter. I was not a typical CALSTAR flight nurse, because most of the crew had been paramedics before they became nurses, and they understood field work and how the EMS system works. I had no idea what goes on in the field, so I had to learn the entire system. I went through a 4-month training program--the first month was all didactic and the next 3 months, I started doing fly-alongs and was slowly integrated into the primary and secondary roles.
You said you started keeping a journal after it was suggested in a CISD class you were taking. Was that the basis for this book?
Yes. I was taking the class to become a CISD facilitator and we were encouraged to write about our experiences. I come from a family of writers, but what I wrote in the journal was not intended for anybody but me. Then, my husband bought me one of the first Apple laptop computers and it became fun to write, so the stories started piling up. As I shared stories with friends and co-workers, they encouraged me to write a book, but I had no idea how to get published, so I found a list of publishers in a directory at the library and sent out letters to several of them. Several weeks later, I got a phone call from someone I thought was a telemarketer, and it turned out to be Lionel Koffler, the president of Firefly Books, who was looking for a book about emergency medical services. It was a time when the TV show ER was popular, and my letter hit Lionel's desk at just the right time. All I had at that time was a raw manuscript that was just a collection of short stories, but with the help of editor Dan Bortolotti and many hours of work, we put together a manuscript. I wasn't really happy with the original version of the book, even though the editor and I worked really hard on it. I like the second edition a lot better.
What do you think made this new edition better, and how much of the first book is included?
We cleaned up a lot of things that weren't right and included better pictures and better writing. We did a new introduction, a new epilogue and a "where are they now" with all of the major characters in the book. We put in a few new stories, but about 80% of the book is the original material.
Flight medicine has gotten a black eye in recent years with so many crashes, but you seemed to have strict guidelines for flying.
When I started flying, EMS on helicopters was a completely new field, and helicopters were crashing because there were no standards. So CALSTAR put together standards, and if someone didn't follow them, they were out of a job the next day. Now there are national standards, and it breaks my heart every time I hear about an accident. Helicopters are dangerous by nature, and one of the things they drummed into us was safety, safety, safety. Industry standards are so tight, I don't understand why there has been such a rash of accidents.
I know you have some health issues. Are there any more books in your future?
I started writing an essay called "MS is a Very Lonely Disease," because it takes a lot of your life away from you. It's actually starting to turn into a book, but I don't know if it will ever get published. There's also a project that some of my old flight crew buddies have been talking about, and that would be a compilation of stories from each person. Many of them have much better stories than mine, so we thought if everyone sent me stories about a couple of their most memorable flights, I could weave them together. If we ever get that together, it would be quite a book. My main focus in life right now is to stay healthy as I can, be joyful and live in each day. My philosophy can be summed up simply: I can choose to live in misery, or I can choose to live in joy. I pick joy.
In our personal flights from hell, we all have a special dossier labeled "pediatric meningitis." Many of these children become desperately ill, despite early and aggressive medical intervention. There is an inexorable downward slide to septic shock--all the body systems speed up to the point where the various organs begin to fail. More often than not, it results in death.
We had been summoned by Children's Oakland to fly to Scenic General--a euphemistically named community hospital in the San Joaquin Valley--to pick up a three-year-old with a working diagnosis of meningococcemia. As I asked questions and took information from our dispatcher, my heart sank. Everything indicated a little kid who was rapidly deteriorating. Yes, his blood pressure was low, coupled with astronomical heart rate. Yes, he was rapidly developing purpura, a purplish rash that quickly spreads and heralds the onset of disseminated intravascular coagulation (DIC) and profound, usually irreversible, septic shock. Yes, his respiratory rate was high, with poor arterial blood gases. And yes, all his blood work was markedly abnormal.
Deedee was my partner that day. Still fairly new to CALSTAR, she had an extensive background in adult critical care and trauma but limited experience in pediatrics. She looked at me quizzically as I wrote down the clinical information.
"What are we going for?" she asked.
"Have you done a meningococcemia yet?"
"A particularly vicious form of meningitis."
"No, but it sounds like I'm about to."
Pete was our pilot. As we headed out into the valley, I pulled out my brain book, the small loose-leaf binder that we all carried in our flight suits. In it we kept up-to-date clinical information, drug dosages and other cheat sheets relating to the conditions we might encounter. Reverently, I opened it to the special section labeled "meningitis." I started with drug calculations, writing down a list of the correct doses.
The closest we could land was a local airport, where an ambulance met us for a ten-minute drive. Scenic General looked like something out of a Hitchcock film. Walking down the ER halls is like running the gauntlet, with people lying on rusting antique stretchers, reaching out to clutch at whoever passes by. There are no windows, just dank halls smelling of human excrement and years of disinfectant.
We were directed into the major medical room. The scene was as I had feared: There was a small child lying on a bed, deathly pale and covered with angry purple splotches. He was awake, terrified and intermittently crying for his mother who was on the other side of the room. His breathing was labored and it was clear he would soon lose consciousness. The team surrounding him was working feverishly, with trash littering the floor because they were too busy to get it into the garbage can. Nurses ran in and out, throwing the requested drugs and equipment onto the bed as everyone concentrated on the frightened little boy, while his mother hovered in the background, trying desperately to understand all the activity.
The doctor at the head of the bed looked up when we walked into the room. I could have cried with relief. It was my old friend Val, who had been a physician in the pediatric ICU at Children's Oakland for years. We had worked together many times, and he was one of the best. He smiled as we walked in. "Janice, so glad to see you guys. Come on in."
The first priority in preparing the patient for the trip to Children's was to intubate him, despite the fact he was awake. Val and I discussed what we needed to do and got busy. Deedee set up our equipment, while mom was watching our every move. I left the bedside to introduce myself and tried to explain what we were about to do. I also wanted to get her out of the room while we performed some of the more invasive procedures--she didn't need to see the intubation--and she agreed to wait in the hallway. "May I just talk to him for a minute before he goes to sleep for the tube? I want him to know I'll be right outside."
"Of course," I said. "When we put the breathing tube in, we'll be giving him some medicine to make him sleepy. But if you talk to him, he may hear you." She nodded and bravely walked up to the bed.
"Sweetheart, Mommy has to go and make a phone call to have Daddy come here to see you, OK? I'll be right outside." Gently she stroked his forehead.
"Mommy, wanna go home please," our little patient pleaded between labored breaths. "Later, OK? I have to go call Daddy." I escorted her out to the hall, sobbing.
Two hours later, we had done all we could to try and stabilize this little boy. We decided we could do no more at Scenic; we needed to get him to Children's. Once again, I thought, another child is dying before our eyes. And we can't stop it.
Val wished us luck as we climbed into the ambulance for the ride back to the airport. I figured it would be a minimum of forty-five minutes until we could push through the doors at Children's. The little boy was hanging in there for now, but forty-five minutes can be an eternity. We set out for the airport with lights and sirens.
As we reached the helicopter, we noted his heart rate climbing and his blood pressure dropping. I increased the dose of his vasopressors, the blood pressure drugs, and Deedee began pushing the fresh frozen plasma we had brought with us. Pete looked concerned. "He sure looks sick," he remarked as we quickly loaded our patient and ran the safety check. "Pete, you have a real flair for noticing the obvious. Now get us the hell out of here."
We lifted off, and turning to our patient, I saw that increasing the vasopressors seemed to be helping the boy's condition a little. I relaxed slightly and started what would be at least a six-page chart. But soon the boy's heart rate starting climbing again, and his blood pressure slowly dipped. We pushed our drugs, but nothing was working. He finally lost his blood pressure altogether, and we started CPR. I got on the radio and called dispatch.
"Rose, CALSTAR One. I need a stat phone patch to the pediatric ICU at Children's." I glanced at the cardiac monitor. His heart rate was now dropping to the thirties. Deedee pushed some atropine and epinephrine. Things were about to get really bad.
Luckily, Andy was monitoring the CALSTAR dispatch radio. "I'm getting Children's on the phone now. Can I relay for you?" I quickly gave Andy an update to pass on to the doctor. "Tell her we're giving epinephrine, atropine and calcium. I've maxed the drips out. We've got no more room to go there. Tell her we'd like to start an epi-cal and an Isuprel drip as well. And find out if she's got any other ideas."
While Andy was calling the PICU, Deedee started mixing up the Isuprel and epi-cal while I continued compressions on the little boy's chest to keep his heart going. Andy called back a few minutes later. "I have the Children's physician on the phone. She concurs with your interventions. Start an epi-cal and Isuprel drip, and run them as fast as you need to get the heart rate and blood pressure up. Continue pushing fluids, colloids if possible." We got the new drugs started in addition to all the rest and, to our relief, his blood pressure and heart rate started to come up. We stopped compressions and began rapidly giving him more fluid.
One of the complicating factors in these transports was that Children's Oakland did not have a helipad at the time, so we had to land at Oakland Army Base and take another ten-minute ambulance ride to the hospital. As we were landing, the boy again lost his blood pressure. We reinitiated CPR and pushed the drips to even higher doses. Pete radioed our dispatch to apprise Children's that the patient had arrested again. We did a hot offload and moved him into the waiting ambulance.
During the ride to the hospital, we were able to get a cardiac rhythm back, but no pulses. We continued compressions all the way into the PICU. As we rolled the gurney through the door at a full run, the hospital staff was poised for action. We moved the boy off the stretcher over to the bed with CPR in progress.
It took almost half an hour to turn over care to the staff in the intensive care unit as we explained what we had done and identified the various IVs. As they took over, I sank gratefully into a chair, shaking. Deedee slumped down beside me. "So this is meningococcemia." We both knew this child didn't have much of a chance for survival. The drop in blood pressure and cardiac arrest had gone on for too long, and nothing was working, not even the big-gun drugs. Slowly we gathered our stuff and headed off to the helicopter.
When we got back to CALSTAR quarters, the new crew was waiting to take over and we discussed the case with them, trying to find a way we could have changed the outcome. As Deedee and I walked to our cars, she reached out and hugged me. "We did everything we could, you know," she said. "We all want him to live, but that doesn't always happen, you know?" She began to cry quietly, then abruptly turned away. "I gotta go home and hug my kids."
I got in my car and turned up the radio as loud as it would go, hoping to drown out the image of our patient lying on that bed, pleading for his mother to take him home. I started to shake uncontrollably and pulled over to the shoulder of the road where I started crying. How could something like this happen? Last night he was a normal healthy kid with a snotty nose, and now he was about to die. I realized I needed to be home with Mark. He'd help, he'd understand. I took a deep breath and pulled back into traffic.
After an eternity, I pushed the front door open. Mark was sitting in the living room, calmly reading the morning paper. I leaned against the door frame, defeated, and burst into tears. He came over and held me as I sobbed. "A little kid, right?" he asked. I nodded, and he held me, rocking me as I cried.
I didn't have to go back to CALSTAR for five days. The first thing I did when I returned was head for the follow-up folder to see how long this kid had hung in there before he died. I had prepared myself and now just wanted some closure. Harry came up behind me, anticipating my moves.
"Guess what?" he said. "Your kid is doing great. He was pretty sick for a few days, but now he's breathing on his own and giving them hell on the floor. He may even be going home next week. What do you think of that?"
What was there to say? Sometimes we can win.