Tick tock

A child’s life in danger

It’s nap time at a Fremont, Calif., preschool when a 50-pound cabinet shears away from the wall and comes tumbling down onto the head of a sleeping 3-year-old girl. On the other side of San Francisco Bay, Stanford flight nurse Shara Griffis, RN, leaps to her feet and bolts out the door the moment the call comes in, at 3:39 p.m. She bounds up the stairs and is off at a near-run down the corridor at Stanford Hospital with her colleague, Jonathan Gardner, RN.

At this point, the nurses have no idea who they are being called upon to rescue, or that a toddler with significant head trauma awaits them some 23 miles away in southern Fremont. They know only that someone’s life might depend on them, and they must make every moment count. In their world, time is everything.

Evan Toolajian, a veteran U.S. Navy pilot, is already in the cockpit of the aircraft when the nurses arrive at the rooftop, home to Life Flight, Stanford’s air ambulance service. They snap on big yellow helmets, then head out the double doors of the flight room in their red Nomex jumpsuits. Their goal is to make it safely from call to takeoff in 7-10 minutes.

Toolajian motions them to stop, then gives the go-ahead as the nurses duck into the side doors of the red, white and blue EC 145. Gardner stations himself in front with the pilot, Griffis in the treatment area in the back.

They’ve agreed to let me fly along to see them in action, seating me next to Griffis. I’m facing the back of the aircraft, my heavy, padded helmet making my head feel as if it’s underwater; I hook it into the radio system, which allows me to eavesdrop on conversations between the flight crew and emergency ground personnel.

I scan the 50-square-foot aircraft, which is better equipped than many emergency rooms and serves as a kind of intensive care unit in the sky. Depending on the mission, it might carry an intraortic balloon pump to support heart function, an ECMO (extracorporeal membrane oxygenation) machine for heart and lung assistance, a sophisticated ventilator and a cardiac monitor, in addition to a full pharmacy of medicines — from narcotics to heart drugs to anesthetics for help inserting a breathing tube in patients who are seriously compromised. 

‘I’m thinking about the right drug doses, the right size of equipment. Where am I going to take the patient? Are we taking two patients? Can we handle two really critical pediatric patients?’

3:49 p.m. The blades whirling, the helicopter rises as its twin engines grind and roar, heading into the mottled sky of a waning Friday afternoon in November. It skirts the towering cranes at the Stanford University Medical Center Renewal Project and glides east at about 120 miles an hour over Palo Alto’s green, tree-pocketed neighborhoods and a wide expanse of brown — the wetlands and brackish water of south San Francisco Bay. It rises to 1,200 feet, and a blast of cold air whooshes into the warm cabin.

The radio is crackling with information from firefighters and paramedics at the scene. There are two injured children, not one, at the Fremont preschool. The flight nurses are the face of calm, but their minds now are buzzing with dozens of questions as they anticipate the needs of a critically ill 3-year-old.

“I’m thinking about the right drug doses, the right size of equipment,” Gardner says later. “Where am I going to take the patient? Are we taking two patients? Can we handle two really critical pediatric patients? How are we going to reconfigure the aircraft?”

He turns on the suction machine, in case he needs to clear vomit or other obstructions from a patient’s throat. He’s calculating the right dose of the calming drug Ativan in case a child suffers a seizure, and figuring out what size breathing tube will fit the throat of the average 3-year-old. “Pretty much it’s always thinking three steps ahead,” he says.

Gardner, 38, is, like all of Stanford’s 13 flight nurses, a highly trained clinician, with skills that go beyond those of a paramedic or the average nurse or even some physicians. He can thread a line into a patient’s artery to monitor blood pressure second by second, or insert a breathing tube in a patient with burns or face trauma. Tall, blond with an intense look, he is a former police officer, paramedic and emergency nurse now acquiring specialized training in anesthesiology while still working full-time. “We’re all overachievers,” he says with a grin.

His partner, Griffis, 40, also works as a critical care nurse at the Veterans Affairs Palo Alto Health Care System to keep her skills up and is studying to become an instructor in mindfulness-based meditation, which can be useful in crises like these. Petite, with a raft of long, black curls, she throbs with energy while in the hospital, but like her partner, her expression remains neutral throughout the call and her movements are carefully measured, not betraying the urgency of the situation.

The nurses are essentially on their own, making second-by-second decisions about patient care. “The flight nurses don’t need a lot of physician input, though we have that available,” says Michael Baulch, RN, JD, Life Flight’s program manager. “They are independent decision-makers. Mostly, they are very calm, which is one of the most important ingredients. We have some very chaotic situations. They’re very good at establishing presence at a scene.” 

3:55 p.m. Just six minutes after takeoff, the pilot, guided by GPS and coordinates provided by emergency ground crews, says he now has the school in his sights. He is maneuvering his way through some birds, who could get caught in the rotors and bring the aircraft down. The school is situated midway between two major freeways, Highways 680 and 880, in a densely populated area with lots of air traffic, and there are hazards to navigate — high-voltage power lines that can easily snag a rotor, fences and debris on the ground and a horde of bystanders next to four emergency vehicles with flashing lights.

“If you see anything unsafe, call us off,” the pilot tells the ground crew, as he takes an extra few minutes to hover over the area and reconnoiter. It’s precious time lost, but safety comes first. Every year, air ambulances around the country go down in the course of their missions, making medical flight work one of the most dangerous jobs in the United States.

“One thing that goes through my mind every day is how many of our colleagues die,” Gardner says. “Every time we show up to work, it’s not 100 percent guaranteed. I’m at the pilot’s mercy. But that’s why we have awesome pilots here…. In an industry like this, you can’t have one moment of complacency.”

Fortunately Stanford Life Flight, California’s oldest air ambulance service, has never suffered a crash in its 30-year history, says Geralyn Martinez, RN, who has been a flight nurse with the service for 23 years.

4:02 p.m. The pilot makes a gentle landing in a dirt- and weed-filled field behind the school, as emergency crews rush forward with a gurney. There is the tiny face of a girl, her neck supported by a brace, peeking out from a welter of wires and blankets. Fremont Fire Department battalion chief Tom Mulvihill briefs the flight nurses: The girl has vomited twice. Her throat has been cleared and she’s on oxygen. She’s been going in and out of consciousness. She’s been very lethargic. They’ve put her in a cervical spine brace, as they don’t know if there is an injury there, which could lead to paralysis.

But time has been lost. The accident happened around 2:30 p.m., according to Fremont fire officials, who said school officials failed to call 911. They only alerted the child’s mother, Avani Bhatt, that her daughter had a “bump” on her head, Bhatt says. With no hint that the situation was urgent, Bhatt, a pharmacist at a Fremont drug store, waited for a co-worker to take over before she headed to the school. When she arrived 45 minutes later, she was stunned: Her injured little girl, Aeshna, was propped up in a chair in the corner alone, obviously unwell.

“She was throwing up, and when I called to her, ‘Aeshna,’ her eyes were rolling, and soon she passed out,” the mother recalls. There was blood on the girl’s shirt and on her bedclothes. “I was really upset and worried about the whole situation…. My biggest concern was to get her the care she needed. The moment I saw her, I knew she was showing signs of head injury — passing out, not answering questions, throwing up. There were obvious signs that something was wrong.”

Aeshna is usually a noisy, active, restless child, who loves to run around and do somersaults and resists sleep, her mother says. She is a terrible tease, often playing tricks on her 7-year-old brother. But there she was, sitting motionless in the chair, nodding in and out of consciousness.

Bhatt called 911 at 3:13 p.m., and Fremont paramedic/firefighter Daniel Viscarra was among the first to arrive, five minutes later. He found a spectral, dazed little girl in the chair, vomit on her shirt. She was unusually quiet and failed to react when he tugged on her arm to check her blood pressure, he says.

“Three-year-olds don’t let you do vital signs. They will cry. They are scared and will push you away,” he says. But Aeshna didn’t resist.

Another child, he discovered, had also been injured in the accident, with a big bump on his forehead, but he was crying and answering questions and behaving like a normal 3-year-old. He was taken by ambulance to a nearby community hospital, where he was treated and released later that day.

Meanwhile, Viscarra tended to Aeshna, clearing her throat, giving her high-flow oxygen through a mask and attaching the cervical brace, in case there was injury to the upper spine. He decided to summon Life Flight, as the girl needed to get to a trauma center as soon as possible.

“Time already had lapsed. If she had a head bleed, it could be significant by that time. The survival rate goes down after an hour,” he says, referring to the crucial “golden hour” after which trauma victims can quickly deteriorate.

Particularly in cases of severe head trauma, time is of the essence. One of the biggest concerns is bleeding in the brain, either from a large vein or artery or from brain tissue itself, says Greg Hammer, MD, a professor of anesthesia and of pediatrics who later treats Aeshna at Lucile Packard Children’s Hospital Stanford. If a bleed is not recognized and treated promptly, it can press on the brain and lead to a cascade of calamitous events, as tissues may die for lack of oxygen, leading to irreversible brain injury, he says. 

4:12 p.m. Aeshna is loaded on a gurney into the helicopter and secured in place next to a heart and blood pressure monitor, which tracks her moment-to-moment status. Because she was injured in Alameda County, county protocol dictates that she be brought to Children’s Hospital Oakland, unless the family prefers otherwise. Her mother opts for Stanford.

Gardner, the flight nurse, makes a split-second decision to offer Bhatt a front seat in the helicopter, though family members are rarely allowed to ride along in these situations. They can be too much of a distraction, and critical minutes may be lost in getting them situated, Griffis says. And if the little girl deteriorates along the way and the mother hears crisis chatter on the radio, she may panic.

“I have someone I don’t know in the front seat of the helicopter, and I don’t know what they will do,” says Griffis, who can’t recall another instance in her seven years with Life Flight when a family member rode along on a 911 call.

But Gardner has made a quick assessment of the mother, who, while visibly upset, seems to be keeping her emotions in check. He has noted her attire, including her black suede sneakers, is suitable for running in the event of a crash landing. Most important, she will be there to comfort the little girl when she arrives in a strange place.

Gardner takes a seat in the back of the aircraft, helping monitor Aeshna, who is now anchored in a head brace and whose eyes are fluttering in and out of sleep. Griffis massages the little girl’s throat and face to keep her stimulated. At times, the child is staring into space, and Griffis waves her hands over Aeshna’s eyes to elicit a blinking response and ensure she is still breathing. Gardner checks the girl’s eyes with a flashlight to see that her pupils are constricting — a sign of normal brain stem function. And he injects her with an anti-nausea drug to help prevent vomiting.

The little girl seems so still and her responses so limited that the nurses worry she could quickly deteriorate.

“I’m thinking, OK, if she codes [goes into cardiac arrest], what is the nearest hospital where I can take her?” Griffis says later. 

4:26 p.m. Just 47 minutes after the call to Stanford, the helicopter glides back over the bay, the Dumbarton Bridge visible through a haze in the distance. The aircraft approaches Palo Alto, passes over the Stanford Stadium, then begins to vibrate heavily as it prepares to meet the helipad.

The back door of the aircraft is opened, and hospital security officials swiftly offload the gurney into an elevator and down to the first floor. A greeting committee of some 15 doctors, nurses and technicians is waiting in the hall just outside the emergency department to welcome the little girl and wheel her into the trauma room.

4:47 p.m. The clinicians cut through her red T-shirt and remove the head brace to reveal the little girl’s slender frame and her shock of black hair. They gently poke and prod her to see if her limbs are working and ask simple questions to gauge her mental status. “Who is this?” asks emergency physician Phil Harter, MD, pointing to her mother. “Is it your daddy? Is it your uncle? Is it your mom? The girl just nods, then yells one of the few words she will utter during the ordeal: “Mama!”

Harter, an associate professor of surgery, orders a CT scan, which will help determine the extent of her injury, and Aeshna is rolled into the big machine next door.

An hour later, results in hand, he issues the diagnosis: Aeshna has a skull fracture and a concussion. She needs to be watched closely for possible bleeding, but no surgery is called for now. She has suffered significant head trauma, and it will take time to heal. He briefs the parents, as the girl’s father has arrived from his job in San Francisco. “Right now, we don’t think she’s at risk for bleeding, but that’s why we’re watching her,” he says. “There is no intervention other than to watch and see that she improves. And that takes time.”

Hammer, who takes over her care in the pediatric intensive care unit at Packard, says there is a depression of a few millimeters in her skull — not enough to put pressure on the brain. But the fracture occurred close to a major artery, a spot where clinicians sometimes see disastrous bleeding, he says. So she is lucky the fracture wasn’t too deep.

The concussion also knocked around her brain inside the skull, jarring the nerves. So she is very sleepy and “out of it” and is prone to vomiting. In the intensive care unit, she is awakened every hour during the night for “neuro checks” — a test in which nurses ask her to grab a hand or answer a question and check her eye movements and see if the pupils are normal. Her scores aren’t perfect, but they are OK. A CT scan the next day again shows no signs of bleeding.

“She was extremely lucky,” Hammer says. “To have this thing fall off the wall and cause a skull fracture and no worse injury, that’s good news…. It’s amazing how lucky some people are, given the circumstances.”

Though Aeshna hasn’t returned to normal, Hammer sees she has supportive parents and he feels comfortable enough to let her go home later that day. She leaves the hospital at 5:17 p.m.

The flight nurses are relieved: “It could have gone differently,” Gardner says. “She could have had a crushed head, blood everywhere. I’ve done CPR on patients on the helipad.”

Because the nurses operate independently, they feel ultimately responsible for the outcome. “It’s emotionally taxing,” Gardner says. “If that kid didn’t have a good outcome, we go home with that. You feel it’s all on you.”

Four days after the incident, Alameda County officials shut down the preschool because of multiple code violations. The loaded, 2-by-4-foot cabinet had shorn away from the wall because it had not been properly secured: It was attached only to sheet rock, not to studs in the wall, says Diane Hendry, a division chief in the Fremont Fire Department.

Back at home, Aeshna is slowly recovering in a process that could take months. She has to limit her activities so her brain does not become fatigued. That means no story books, no exciting games, limited TV watching and certainly no somersaults or headstands, as any further injury to the brain could cause long-term problems, such as cognitive difficulties or memory loss. That is a tough prescription.

“She has resumed activities and wants to do all things, but it’s hard to keep her tied down to bed,” her mother says. As a result of the accident, the family went to India for a few weeks to stay with relatives, who helped provide support and care, she says. She says she is optimistic about Aeshna’s prognosis, but she is nonetheless shaken by the experience.

“It looks like it’s going well, but you have this insecurity in the back of your mind until she has a full recovery,” Bhatt says. Like the accident itself, it’s all a matter of time. 

Ruthann Richter is the director of media relations for the medical school's Office of Communication & Public Affairs. Email her at richter1@stanford.edu.

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