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on my blog: MitchelMD.com

The following is an excerpt from 50 Flights: A Physicians Coming Of Age


I must now go a long way . . .
I must face fighting such as I have not known, and I must travel on a road that I do
not know!
~The Epic of Gilgamesh, Tablet III, 2100 B.C.

I was rummaging around the external compartments of the helicopter as sweat
dripped down my face. The heat was unbearable, and my slippery fingers had
trouble grasping when my radio toned. Time to fly. The heat inside the hangar was
stifling. It would be our third flight that day and the veil of fatigue that inevitably
descends after twelve hours of intense stress was beginning to take its toll on my
spirit.
I raced inside with the enthusiasm of a small child and took the call. Flying never got
old. I love the rush of adrenaline from takeoff and the thrill of speed coupled with
the chance to use my medical skills. Immediately a sense of dread overtook me. I
could feel an unwelcome pit open in the bottom of my stomach as I listened to the
physician on the other end of the phone relate the brutal details. Some cases are
more emotionally charged than others. This one would prove to be one the hardest
cases Ive yet to have in my career.
A story unfolded that a six-year-old child had been playing in the yard and had
apparently wandered out onto the road. The family lived in a somewhat remote
area, and it was not unusual for cars to travel in excess of 60 miles an hour on the
gravel road in front of their home. As suppertime time approached, the father went
out to find his son and couldn't locate him. As he walked down the road calling his
sons name, he found a single shoe. He immediately began screaming for help! The
child's mother and several older siblings raced out and began to scour the
immediate area. They soon located the child on the opposite side of the road

crumpled in the ditch. There lay their precious childbattered bruised, bloody, and
unconscious. A senseless victim of another hit and run.
The local ambulance crews responded quickly and found a shattered family holding
their precious soul. A paramedic scooped the child from the sobbing father's arms
and ran back to the ambulance for a short transport to the local hospital where the
ER staff immediately took over. They secured his airway with an endotracheal tube
and inserted several IVs into his arms to begin the process of pouring life-giving
blood and fluids into him. These are standard but critical actions in an attempt to
save this fragile, precious little life. The size of the child and the critical nature of his
injuries only compounded the difficulty in this case. The clicking sound of his
shattered ribs along with dramatic bruising on his torso and abdomen signaled
horrific injuries below. His small body was no match for the speeding metal of a
passing car.
As we landed and exited the aircraft, the paramedic gave me a knowing look. We had
dealt with children in critical condition before, but this was going to be different. We
entered the back of the emergency department and felt an overwhelming
somberness like a thick layer of fog. The child's condition had rapidly deteriorated
since our initial phone call. The endotracheal tube was leaking and forced bubbles of
blood from the child's mouth. Both parents were at the bedside, sobbing. The father
repeating, over and over again, "My big boy, don't leave me."
As our team began to assist in the care of this patient, I could feel the tears welling
up in my eyes. I had just recently experienced the birth of my child, who was now
just a few months old, and I called him "big boy." Every time the father would say
those words, "My big boy, don't leave me," I could feel my heart strings being tugged
even harder. An intense focus was required to stay on task.
It was apparent that we needed a different endotracheal tube. I instinctively took
control over the airway and began preparations to place a larger tube to better
secure the airway. His oxygen level was dropping, and we had to act. In trauma, the
airway takes precedence over all and is the first step in managing critical cases. As I
looked into the back of the throat with the laryngoscope, I was met with an angry
pool of blood. With some difficulty, I was able to visualize a sliver of the epiglottis

and see the leaking endotracheal tube's location. I gave my paramedic-nurse the nod
to pull the tube and then I deftly slid in the larger tube to secure the airway
following alongside the old tube as it was pulled from his lungs. My sense of
accomplishment and relief at completing this vital task was short lived. We began
the process of transferring the child to our stretcher when he flatlined. The local
physician began to pump vigorously on his chest, trying to usher life back into his
fragile little body.
Statistics show that any person who suffers cardiac arrest from trauma has a very
poor outcome. This case was no different, but all healthcare providers I had trained
under always gave children the extra benefit of the doubt. These little souls had not
yet lived or experienced the joys of life and terminating resuscitation efforts in any
child is a difficult decision. Even if all the evidence supports that the case is futile, we
continued throwing all the technology, medication, knowledge, and skill into the
arena - hoping that there'll be some positive response. Letting hope take
precedence over the science and any statistic, even if just for a fleeting moment. All
we ask is just some small glimmer of hope or even the slightest hint of response
showing that we can bring this child back from death.
After what seemed like an eternity, we all knew it was time to stop the resuscitation
efforts. We had lost. Time stood still, and final act was rapidly drawing to a close. I
asked the social worker to escort in the grandparents. We had been alerted to their
presence only moments before and sensed they would want to be at the bedside. I
stepped away from the head of the bed, as did many of the other staff, with the
exception of the physician who was still performing chest compressions and the
therapist who was pushing oxygen into this child's tiny lungs with a bag valve mask.
The best efforts of our team had failed.
The family crowded around the bedside, each taking a hand of the child and gently
stroking his face, but among all the outpouring of love, tenderness, and grief, its the
father's final words I will always remember. As we stopped resuscitation efforts, he
whispered, "My big boy, I'll always love you. Forever." And with that, he leaned
down and kissed his child good-bye.

I hope you enjoyed this mission and have gained an understanding for life
on the front lines of emergency medicine and trauma care.
Please share this if you enjoyed it.