A Final Arc of Sky: A Memoir of Critical Care Paperback - 2010 - 1st Edition

Chapter One: The Shadow We Cast

When I parked my car at ten minutes to nine that summer
morning and dragged my helmet, flight bag, food, and laptop up
the stairs at the southernmost of our four helicopter bases, the
last dregs of predawn coolness still lingered in the air. I was in
a good mood. I had just blasted the B-52’s Cosmic Thing on my
car stereo, playing my favorite tracks over and over like a fiveyear-
old for the hour and a half it had taken me to commute to
the base from home for a twenty-four-hour shift. The National
Weather Service had predicted temperatures in the nineties, but
the heat hadn’t yet begun to shimmer off the helipad back behind
the fire station where we were quartered.
 
The fire station is tucked into a rural corner of a mediumsized
suburban city, next to a county airfield, and the landscape
around it was cleared of its native forest a long time ago. It’s as
open as farmland in Kansas, dotted with Scotch broom, an invasive
weed that is nevertheless lush with tiny yellow blooms each
May. The sweep of the earth falls away to volcanic mountains
in the distance, still snow-covered even in summer, and on my
speed walks around the fire station for exercise I’d come to love
it, in spite of the landfill that’s practically next door. I loved the
light and space, the foothill feeling of the land as it runs imperceptibly
up toward the mountains.
 
The day felt pregnant, though—that occupational precognition
I’ve come to trust and dread. It’s a feeling with a dart of
fatalism in it, a blind, nonnegotiable foreknowledge, and I’ve
learned the hard way that it’s pretty accurate. Not 100 percent
infallible, but up there. Whenever the feeling comes on me, I
think of the animals who head to high ground before a tsunami,
whose nervous systems seem to warn them of earthquakes and
floods. Rats deserting a sinking ship.
 
It was also a Friday in high summer, so no shit, Sherlock,
of course we’d be busy. We could look forward to office workers
ordering margaritas at outside tables in the hot afternoon
and driving home wasted in the dusk. Guys with huge guts and
crap in their coronary arteries pushing their lawn mowers in the
heat around their acre-and-a-half yards. Stoic eighty-year-old
Scandinavians deciding it was time to climb their twenty-foot
ladders and clean the old moss off their roofs.
 
Jason was my partner. We chatted with the off-going crew,
lingering over our coffee in the sturdy firehouse kitchen. Eventually
we strolled out into the fine summer sunlight, across a
short expanse of pavement, and under the main rotor to check
the helicopter and our medical bags for completeness and readiness.
Everything looked good. No blood splatters on anything,
maybe just a couple of small things missing, and we replaced
them. At the time, I had been a flight nurse for about three and
a half years. Jason had just transferred from another base; I’d
met him and talked to him at meetings, but we hadn’t flown
together before. He was our youngest flight nurse, about fifteen
years younger than me, which is to say he was fifteen years
younger than most of us, a thing he was teased about occasionally.
He was short and compact, bespectacled, analytical and
smart, calm. We finished our checklists and went into the office
to fax our supply requests to the main base.
 
Jason put his feet up on the desk and said it was almost a year
to the day since he’d started with our outfit. “My first flight,”
he said, chuckling, “was CPR in progress for thirty minutes in
the aircraft.”
 
“Ouch! Was it trauma?”
 
“Yup. A rollover on the freeway. It was . . . stressful.”
 
“Was CPR already in progress when you took over the care
of the patient?”
 
“Yup.”
 
“Hah! That is stressful, especially for a first flight,” I said,
picturing it and laughing a little. On your first-ever flight, the
rush of foreign sensations—the vibration, the roar, the cramped
quarters, the whizzing landscape—makes the simple act of strapping
yourself in to the helicopter enough of a challenge.
 
“But to my mind it’s not the most stressful situation,” I
added. “I mean, when you get trauma patients with CPR in
progress, yes, it’s an exercise in doing everything possible, but
they’re basically dead already. You can’t hurt ’em.”
At that point, I was thinking of a physician friend, my own
gastroenterologist. I see him for gastroesophageal reflux—
chronic heartburn, and who knows whether it’s because of genetics,
the two ten-pound babies I’ve borne that mashed my
insides to a pulp, or this job. He told me once that when he’d
first started out in medicine, he was scared to take care of really
sick—critical—patients.
 
“But then I realized,” he’d confided, grinning a little, “that
they only get so sick, and then they die.”
 
Yeah.
 
“The most stressful situation,” I mused aloud to Jason, “is
when they’re lying there talking to you and then they code. The
ones who roll back their eyes and die right there.”
I can’t remember if I mentioned to Jason that it was a situation
that had never yet happened to me in flight, but it hadn’t.
And for all my years of experience on the ground and in the air,
I didn’t know how well I would acquit myself if it did.
I must have temporarily lost my mind, saying such a thing
with that fatalism sitting like a stone in my stomach, with the
twenty-four-hour day so early in gestation and our flight suits
so clean, with the caffeine of the morning coffee still running in
our veins. Saying such a thing on a Friday in summer.
Jason snorted. The harsh fluorescent light on the office
ceiling flashed off his stylish little glasses, and I couldn’t tell
what he was thinking. It was probably something like Now she’s
cooked our goose. “Well, yeah,” he said. “No question about it.
That would be the worst.”
 
It was early afternoon when the pager shrieked for the first
flight of the day. We kicked off our sandals and zipped up our
boots and our flight suits, and off we went to a small community
hospital, a thirty-minute flight toward the coast, over open valleys
and rivers winking like bottle caps in the hot noonday sun.
Brad, our pilot, dropped the aircraft down light and easy onto
the helipad, and Jason and I slid our stretcher, bags, and monitor
out onto a gurney. We trucked the whole thing in through the
emergency department door and up to the ICU on the second
floor.
 
Our patient was Doug. He was forty-six years old, with
esophageal cancer and an upper gastrointestinal hemorrhage,
and we were transporting him to an oncology referral center,
where they had more resources to deal with his problems. His
esophagus, which transports food from the mouth to the stomach,
had a large tumor on it, and he had been receiving chemotherapy
and radiation to debulk it, to shrink it enough so that a
surgeon would have a shot at removing it. Apparently, a blood
vessel in that region had eroded earlier that morning. It had
gouted large amounts of blood.
 
A hematocrit measures the percentage of the volume of red
blood cells in the total volume of blood and is used as quick
guide to how much blood has been lost and how well it’s being
replaced. A normal crit is about 40 percent. After he started
vomiting blood, Doug had an initial crit of 17 percent. He had
received five units of packed red blood cells and other blood
products since that measurement had been taken, but there
hadn’t been a repeat crit. He had not vomited any blood recently,
and he came with a tube that had been surgically placed
in his stomach through his abdominal wall—there wasn’t much
output from that, either. We could assume that the bleeding
vessel had clotted off. For the moment.
He had other problems too. A collection of straw-colored
fluid between his left lung and the pleura, the covering around
his lung: a pleural effusion caused by impaired lymphatic drainage
secondary to his tumor. The ICU staff had just drained
520cc—more than two cups, quite a bit. I hoped it wouldn’t
reaccumulate too quickly. He also had a small pneumothorax of
the right lung. This was a collection of air between the pleura
and the lung. The problem for us was Boyle’s law: air expands
at altitude, and aloft a small pneumothorax can become a large
pneumothorax, collapsing the lung and, if it’s big enough, compressing
the heart and the great vessels that transport blood
into and out of the heart. In an ICU, a big pneumo would buy
the patient a chest tube so air could drain continuously. At altitude,
if it became a problem, Jason and I would temporarily
treat the pneumo with a flutter valve—a large-bore, sharp steel
needle that had been sterilized with a disposable-glove finger
rubber-banded to the hub. The glove finger acts as a one-way
valve. We’d stick the needle through his chest wall, into the
space between the second and third rib, and it would allow air
to escape.

In this compelling memoir, her moving reflections on life and death interweave clinical encounters with her own life. . . . Culkin sees herself and others clearly, and poetic juxtapositions make her sentences soar.—Publishers Weekly

"A marvelous writer, mixing tragedy and reflection with luminous prose . . . We are privileged to share her passion and heartbreak."—Marilyn Dahl, Shelf Talker

""With its perfect capture of the fragility of life and our vulnerable human bodies and bonds, A Final Arc of Sky . . . is a disturbing, powerful read."—Lynda V. Mapes, Seattle Times

"Rarely have we heard from such an eloquent yet urgent voice from the front lines of mortality. . . . Culkin writes with elegiac grace and unblinking honesty."—Robin Hemley, author of Invented Eden

"Absorbing . . . This former neonatal and pediatric intensive-care nurse has vivid memories of the tiny patients whose lives were in her hands, and she writes of them with warmth and clarity. . . . Powerful and lucid . . . The risks of being an emergency flight nurse-night flights, bad weather, human error-come fully alive. . . . Enthralling."—Kirkus Reviews

"With her electrifying scenes, her gorgeous sentences, and her provocative explorations of the borderland between life and death, Culkin engaged my heart, my intellect, my artistic sensibility, and my adrenaline."—Ann Pancake, author of Strange as This Weather Has Been

"I loved the stories, the language, the point of view, but what I loved most was the way this book was able to break my heart—then mend it."—Judith Kitchen, author of Distance and Direction

Jennifer Culkin, winner of a 2008 Rona Jaffe Foundation Award, is a writer and longtime neonatal, pediatric, and adult critical care nurse. A graduate of Russell Sage College and the Rainier Writing Workshop at Pacific Lutheran University, her work has appeared in many literary magazines and in The Jack Straw Writers Anthology 2006.