Estimated reading time 11 minutes, 20 seconds.
It was the last hour of the last night of a week’s worth of work. I had rolled out of bed, cleaned up, straightened up, and was making coffee. A week off beckoned. In my mind, I was already on the boat.
Alert tones sounded across all three radios in our quarters.
I listened to the scene-flight assignment, and told the comm-center I would check weather. I didn’t want to go, but the ceiling and visibility weren’t bad enough to get out of the flight. The forecast was okay. No mention of fog, but we had a conjoined temperature and dewpoint.
“Base, LifeStar responding.”
My nurse that morning was Jillian. She is a veteran of trauma-centers in South Africa. Real trauma centers. Don was the medic. We had worked together for a couple of years. I had helped him work on dead people, who then proceeded to be undead. We had a bond of trust. He had skills. I had skills. We liked each other.
We headed northwest from Savannah into the country. Once you cross I-95, it’s a different Georgia. Rural. Two-lane roads. Pastures and plows and pine trees. Daylight was fresh upon the world, and the air was still and heavy. The vents for the air conditioning were streaming a cool, moist fog; the system in a BK117 cools the air, but doesn’t remove moisture. The air outside was saturated, but still clear. Heavy gray clouds hung low overhead. “At least it’s daylight…”
Thirty miles northwest and we came to our scene, a country crossroad at which a truck and car had arrived simultaneously, neither stopping. The truck won. I got the landing zone briefing over the radio, did a recon, and landed in a field. My crew tromped off to get the victim. I started working on forms.
Don came back.
“Can we take two?”
“What’s their total weight?”
“Okay, it’s going to take a few minutes — the lady is entrapped pretty badly. These people are circling the drain.”
“Roger that.” I set up the GPS, and entered frequencies into radios. I called the comm-center and advised “two patients, both trauma-alerts.” After a 20-minute delay, the procession headed to the helicopter: firefighters, medics, and my crew — one per patient. We loaded with the engines running, and after the helpers were clear I advanced throttles and asked for the before takeoff checklist.
Don called off the checks. I responded and asked him to clear us left, right, and overhead.
We blasted off.
As soon as I cleared the trees, I could see tendrils of mist coming up out of them. The atmosphere had become sufficiently saturated to produce fog, and it was happening rapidly.
I was now in a race.
I could hear Don and Jill working, talking about what to work on first. Blood was coming from multiple injuries. They were very busy. I gave a short report to the comm-center and said that the crew might be too busy to call. “Please have help at the heliport.” As we neared the coast, the visibility got worse. I began to feel the gut-ache of pressure. I heard a Delta pilot tell Savannah that he needed to hold west of the airport for some weather.
I called Savannah approach, used “Lifeguard,” and asked for direct routing to the hospital. The weather got worse. The patients got worse too. I could hear fatalism in the crew’s voices.
Then the voices in my head started. “Go faster. Faster. You have to get them to the hospital — now!” This was countered with, “The weather is going south. You need to stop somewhere — now.”
We rolled across I-95, and I changed to the tower frequency. The tower controller announced two miles of visibility and said, “What are your intentions, LifeStar?”
“I need a special VFR clearance across the airport at 500 feet, I have two crash victims on board. I am trying to get them to Memorial.”
I was totally caught up in the drama. Patients dying. Not enough weather. Not enough time. No good choices. What to do, what to do, what to do?
I was in a “naturalistic environment.” These require “naturalistic decision making.” Making choices when a lack of time to think is coupled with extremely high consequence is hard. It’s excruciating.
My crew and I and those two dying patients? We were between a rock and a hard place. I could sense that I wasn’t making good decisions.
Human factors were working against me.
We blew across the runways at Savannah International. A safe landing was right there for the taking. My head said, “Land! Call for an ambulance. Stop!”
My heart said, “They will die.” I was very uncomfortable. I called the comm-center to update them. Jill could hear the anxiety in my voice. She said, with her accent, “Daaan, you are doing a wonderful job…”
I didn’t feel wonderful. Another pilot flying a helicopter 10 miles ahead came on the frequency and advised that the weather was much better where he was.
The runways disappeared behind us.
I was down to 300 feet. Only five miles to go. I was thinking aloud, “Okay, where are the towers between the airport and the hospital. Don’t hit a tower. Don’t hit a tower.” I was leaning forward, almost to the glare-shield. The visibility was getting worse and worse. I could see the ground below me, but not much to the front. I had taken us into the clouds in a visual flight rules (VFR) helicopter without an instrument flight rules (IFR) clearance.
“Man. What a mess.”
I wasn’t worried about flying in the clouds, because I did that frequently both in military service, and while flying for Penn State and Geisinger’s IFR flight programs. I was, however, acutely worried about hitting something. I knew I could climb and get a clearance and shoot an approach. A part of me wanted to. But that would take time. And blood.
The pressure was like a piano on my back.
But it was all in my head. The entire situation was something that my cognitive and emotional selves had concocted, but that my behavioral self was having a hard time resolving. I was taking my crew and those two patients further and further into an untenable situation. Why?
Good helicopter emergency medical services (HEMS) pilots don’t earn their pay for always saying yes. Good HEMS pilots earn their pay for having the wisdom and courage to say no. And we can say no (further) at any stage of a flight. We don’t have to press on. The fact that the patient might die is not a valid justification for us all to die. Or to accept undue risk. It’s okay to stop. It’s a harsh truth, but truth it is… even if there is a kid involved.
I know this now. I learned that lesson that day. I lived because of dumb luck. I didn’t hit a tower by sheer chance. I flew by a crowd of them. I stumbled across a military airfield near the hospital and finally came to my senses.
“Tower, LifeStar declaring an emergency, landing at Hunter Base Ops.”
“Comm-center, send two ambulances to Hunter Base Ops please. I am landing for weather.”
I shut down, climbed out, and felt horrible. What a mess. I opened the clamshells and the back of the aircraft looked like a combat hospital. Blood dripped off the floor onto the cement. Jill and Don were both sweating, working, trying.
The ambulances arrived with reinforcements. Grim faces.
Both of those patients died. They would have died no matter what I did, and I could have killed us all trying to save them. This is a hard lesson. It’s okay and understandable to feel compassion for our patients. But our prime directive is to save the crew. Every decision we make should be with an eye to that end — that our crew goes home safe at the end of their shift. Save the crew. Let the crew save the patient. They can work toward this either in the air or on the ground. You don’t have to keep going.
In an excellent old U.S. Air Force training film Ejection Decision – A Second Too Late (available on YouTube), the Air Force explored the phenomenon of fighter pilots waiting too long to eject from a crippled jet. This happens less often in combat environments, perhaps due to less worry about destroying an aircraft. They show graphic images of planes crashing, sometimes accompanied by a blossoming parachute, sometimes not. The message is clear. When the jet fails, you should eject. Don’t wait. Don’t try to sort things out. Remove yourself from that situation. There isn’t time for reflection. There is too much pressure.
There is too heavy a price for hesitation.
More than one pilot being interviewed stated that his decision to eject wasn’t made in the heat of the moment. The decision was made years before, in training, after careful thought. “If I encounter these conditions, I will take this action.” These guys made their decision early. When they encountered the conditions they acted. Without thought. Without hesitation.
If you are a HEMS pilot, you should make your “decision to eject” now. Before you are sitting in the hot seat with someone dying next to you. Weather, maintenance, fuel state? It is going to happen to you. And if you hesitate, you may not be as lucky as I was that morning, all those years ago.
HEMS flight teams: When a patient is on board, are the crew absolved of any obligation to monitor the man-machine-environment? What could/should the crew have done when they heard the obvious anxiety in my voice and saw the low altitude I was flying at to avoid the clouds? It is easy for a team to become so focused on the objective that they accommodate to excessive risk, as one. When this is happening, someone must think and speak rationally — it may have to be you.