The Final Miracle
How Death Was Cheated In Paradise






Henry Lancing Woodward


 
© Copyright 2022 by Henry Lancing Woodward

Photo by Asad Photo Maldives courtesy of Pexels.
Photo by Asad Photo Maldives courtesy of Pexels.

I believe it is impossible to adequately describe or explain what it is like to be a Paramedic. It is something one must live in the moment. In a true emergency, every one of those moments is a lifetime, especially for the patient. As a Paramedic, either for one moment or years of moments, one becomes altered to the very core. That’s why I’m not going to try to describe it. The only way I know to help you understand is to tell the story of one of the most intense and successful cases I attended that, ultimately, included an unrelated tragedy. But first, you need some background information.

I worked the ground ambulances in Hawaii with a partner and the inter-island air ambulance where I was the sole medical provider, no partner. While staffing the ground ambulances, I could see everything from twisted ankles and runny noses to complete cardiac arrests and everything in between. I never knew what the next call would be. But, working the air ambulance was different. In this ambulance, we transported only extremely critical patients. Extremely critical patients. There was no doubt about what the next case would be. I knew it would be life or death. Always.

These patients needed specific and immediate advanced life support care that was not available at their present location. They had to be taken to the care they needed and that care was an ocean away. They had to be flown. I did this for about a year and a half, and this is just one of several hundred cases I attended. Again, all of them were life or death, but none other was so dramatic or successful.

We used a non-pressurized two engine, fourteen seat plane with the seats removed. There was a mounting device for the gurney built onto the floor. The non-pressurized cabin meant whenever we had a head injury patient we were required to fly about five hundred feet above the waters of the Pacific Ocean and this is a very dangerous thing to do for a prolonged period. Also, for this type of emergency, the time factor was critical. We had to fly just about as fast as we could, at almost one hundred and eighty miles per hour. Too fast for this altitude, especially over a warm, tropical ocean.

Again, at that altitude and airspeed, if anything were to happen, if we hit a bird or were tossed by a warm up draft off the ocean, or if we were pushed by a strong cross wind or anything else, the chances were good we would end up in the Pacific Ocean. There wouldn’t be enough time for successful corrective actions. We took this life-threatening risk to ourselves whenever we had a patient who was bleeding into his brain because flying this low and fast was an important treatment for this bleeding, and this is why.

With any bleeding, it is important to control it as soon as possible. This includes bleeding that is either external or internal. Until proven otherwise, it was our job to assume our patient was bleeding into his brain. The air pressure is greatest nearer to the surface of the earth than it is higher up. By flying as low as we could, the increased air pressure would apply natural “direct pressure” to the bleeding site which would hopefully slow or stop the bleeding.

Also, it was imperative to get the patient to a neurosurgeon to definitely find and control the bleeding site as soon as possible. Increased external air pressure could only do so much. To do that, we needed to fly as close to our maximum air speed of one hundred and eighty miles an hour as we were able. The combination of these two factors, a low altitude and a high rate of air speed was potentially a very deadly mixture we were willing to risk for the benefit of our patient.

In a head injury where the brain is bleeding into itself, the pressure inside the skull increases. When this happens, something called the Brain Stem becomes affected. As it descends from the underside of the brain and passes through a small hole in the floor of the skull it becomes the neck spinal cord. Then, it continues downward to become the back spinal cord.

Because the skull is a closed space, if the brain does swell, there is no room available to accommodate it. As it increases in size, it causes pressure on the inside walls of the skull by pushing outward in all directions. The downward part of that swelling and pressure can create a life threatening situation as it tries to push the also swollen Brain Stem through that small hole.

We later learned this was exactly what was happening to the patient we were to soon transport to Honolulu. This process of pushing the swollen Brain Stem through that hole is called the “Herniation Syndrome,” and is an extremely critical and life threatening condition which causes many serious medical problems, usually in this order;

First, and the worst of them all, is Respiratory Arrest - the absence of breathing. Of course, this causes rapid death.

Second, and just about as bad, are the complications caused to the heart beat and the blood pressure. These problems, also, may cause a rapid death or an extended dying process.

Third, if the patient lives, there may be total paralysis from the neck down disabling all four limbs - quadriplegia. This condition is usually a chronic, lifelong problem. In addition to these “big three,” there are other very serious medical problems we shall discuss later. I am explaining all this because it is important information you need if you are to understand the story I’m about to share with you. Here is that story.

This request came into 911 from a doctor on Maui. He had a patient with a “head injury” who needed to come to Honolulu on Oahu for a CAT scan and the services of a Neurosurgeon. At the time, there was only one CAT scan machine in the state and it, along with the surgeon, was at the Queen’s Medical Center in Honolulu. The diagnosis of “head injury” was the only information we had received about the patient and that proved to be unfortunate for the patient and our air ambulance team. If we had known the complete picture we would have brought another person or two with us.

We received the call and arrived at the Lahaina airport about an hour later and were waiting on the apron when the Maui land ambulance pulled up and stopped near our wingtip. The double back doors opened and the gurney was slid out with our patient on it.

The first thing I saw were the three people attending the patient and I realized this was not just a “head injury” alone. If it required three attendants to take care of this patient on the ground, and it did, I knew I was in for a really tough transport in the air. I immediately went to the head of the patient. The first obvious thing I saw was that he was not breathing on his own. This was a bad thing.

While the EMT from the Maui land ambulance continued to breathe for the patient with a squeezable airbag, mask and Oxygen, I moved the bandage some to examine the head. There were four very large open wounds in the scalp and skull and I could see into them and plainly see brain tissue. They were very serious injuries.

It was almost a certainty the brain was injured, bleeding into itself and swelling. If that was the case, and I was sure it was, the Brain Stem on the under surface of the brain was indeed being squashed downward through the hole in the floor of the skull. This was probably the reason that the patient was not breathing on his own.

The need to breathe for the patient by squeezing the airbag with the Oxygen twelve to fourteen times a minute would be the first thing I would need to do during the entire flight. There were also two IVs running and a heart monitor observing the heart beat. In one of the IVs, there was a medicine which was treating the brain swelling and the squashing of the Brain Stem. The other was plain medical water and was there as an injection route for the quick administration of other medications if needed. It could also be used to add fluid to the bloodstream, if needed, in order to maintain a therapeutic blood pressure.

The IV with the anti-swelling medication was critically important and would have to be watched constantly to be sure the flow rate did not vary with the up and down and side to side movements of the airplane. This would be the second thing I would have to do constantly during the flight. The other IV was less critical but still had to be monitored to continue its flow. Fortunately, the second IV would require far less time and attention as would the first.

The heart monitor was for showing problems which could occur with the heartbeat and heart rhythm in real time due to the Brain Stem continuing to be squashed. This was the third thing I would have to do constantly for the entire flight.

This, then, brings us to:

Problem #1: Acute Respiratory Arrest

There was an EMT at the head of the patient who was dedicated one hundred percent to do one job and one job only. That job was to breathe for the patient. He was doing this by squeezing the collapsible plastic air bag designed for that purpose with one hand every four to five seconds without stopping. Ever. Without pausing. Ever.

The bag he was squeezing with one hand was connected to a plastic face mask which he was holding in place over the patient’s nose and mouth with his other hand. The face mask had a plastic tube connected to it. The other end of that tube was connected to an Oxygen tank and was delivering pure Oxygen to the face mask from the tank. The Oxygen would then be forced into the patient’s lungs by the squeezing of the bag.

There was only one way for this to be done effectively. The face mask needed to be held perfectly on the face creating an intact seal with the skin. If Oxygen could escape from under the edges of the face mask where it met the skin, there would not be enough pressure created to force enough Oxygen into the lungs.

Holding the face mask correctly in place over the nose and mouth was the other part of this dedicated EMT’s job. He not only had to ensure it never slipped out of place, he also had to ensure there were no leaks. As you can imagine, squeezing the bag with one hand and holding the mask correctly with the other was truly a full time, two-hand job. Any person doing this job could not do anything else. This case was building into a gargantuan assignment.

Usually, a patient who is unconscious and not breathing on his own would have had a plastic Endotracheal Tube inserted into his airpipe, the Trachea, to seal it closed. This accomplishes the same purpose as holding the mask firmly onto the face and frees the hand that would be doing that to do other things. Also, if there happened to be any vomit coming up from the stomach through the Esophagus, it would not be able to enter the airpipe and get into the lungs. This had not been done for this patient at the scene of his accident on Maui and this is why.

Once the Paramedic had arrived and evaluated the patient, he radioed the ER with his report for the doctor. After the report, the doctor had decided to forego the placing of the tube into the patient's lungs. He reasoned that because the injuries to the head were so severe, there was a high probability that the force causing them had also broken the neck and perhaps had also injured the neck spinal cord.

In order to place a tube into the lungs, the head and neck had to be hyperextended and it was determined by both the Paramedic at the scene and the doctor in the ER that it was an unacceptable risk. The manipulation of the head and neck could cause a devastating injury to the neck spinal cord and the risk of leaving the patient with an open airway was deemed to be the lesser of two evils. This decision caused my job to be more difficult than it should have been. Breathing for the patient was the first full time job that needed to be done while we were in the air.

This, then, brings us to:

Problem #2: Acute, severe head trauma with a fractured skull, swelling of the brain, increased intracranial pressure, and herniation syndrome of the Brain Stem.

This emergency began early in the morning in the Pacific Ocean off the North Shore of Maui. Our patient had been snorkeling with a group of friends. It was a commercial charter that for everyone’s safety always tethered each diver separately to the boat with a long nylon safety line. This way, the ocean currents couldn’t pull them away from the boat while they were diving.
Somehow, on one of his dives, the line tied to our patient had become entangled in the propeller of one of the boat’s outboard motors. As it continued to turn, the line was wound around it pulling the diver right into the blades. His head had stopped the blades and the motor, not the tangled line. This was not a good thing at all. The impacts of the propeller blades must have been tremendous and must have happened at least four times. As a result, they had caused a massive head injury with four large open gashes in his scalp and skull.

The dive company had trained its employees in CPR and rescue breathing. The very nature of their business caused them to be in remote conditions and this was an OSHA requirement. After pulling the diver from the ocean, they had determined he still had a heart beat but that he wasn’t breathing. Immediately, they had initiated mouth-to-mouth rescue breathing and had continued it for over an hour until the arrival of the Paramedic ambulance.

Upon arrival, the Paramedic and EMTs took over and continued the rescue breathing using their squeezable airbag, face mask and Oxygen. Finally, after more than an hour of not breathing on his own, the patient was now receiving pure Oxygen delivered in an effective manner. They also applied a soft neck brace called a “Cervical Collar” to the patient’s neck. This was done to reduce the movement of the neck and thus the neck spinal cord. Once again, because the patient was unconscious this was a medical requirement.

Then, to protect the back spinal cord, they had strapped him onto a rigid backboard that extended the full length of his body. All this protected the neck and back spinal cords very well, but because his airway had not been secured with a tube into his airpipe, if he vomited I would have to roll him and the backboard onto his side to prevent any of the vomit from getting into his lungs. This would be a tough job for one person in a small plane.

The doctor in the ER on Maui had ordered the Paramedic to transport the patient directly to the airport. There was no need to bring him to the ER because the services he required were on Oahu. Taking him to the ER on Maui would only serve to delay the delivery of the medical care he needed, a CAT scan and a neurosurgeon.
Because of this, the doctor on Maui never physically saw or examined the patient and was therefore not fully aware of the extent of medical problems for this patient. When he called to order the air ambulance, he only mentioned the head injury. He neglected to make them aware there were also the problems of non-voluntary respirations and the cardiac and blood pressure complications. That is why we had not added extra EMTs to the transport. We didn’t know the patient needed them. This, too, would come back to haunt us in the air.

This, then, brings us to:

Problem #3: Acute, potentially lethal irregular heartbeat and blood pressure changes.

When I saw him at the Maui airport, the patient was on a cardiac monitor . I had one on the plane because it was part of the equipment required for any Advanced Life Support Ambulance. It would be needed in order to constantly observe his heart activities during the flight to Oahu.

He also would need to have his blood pressure checked at least every four to five minutes, if not more often. Both these actions of watching the heart activity and checking the blood pressure needed to be done for the entire time we were in the air. Monitoring the heart activity and blood pressure was the second full time job that needed to be done while we were in the air.

This, then, brings us to:

Problem #4: Unconscious patient with possible fractured neck and spinal cord injuries.

Because our patient was unconscious and could not tell us that certain things were not a problem, it was medically required to consider there could be other things wrong with him. On the patient’s behalf, we were required to guard against all those potential problems. Therefore, it was assumed that the patient had an injury to his neck spinal cord and an injury to his back spinal cord, and he needed to be treated as those problems really existed, more so because the odds were they really did.

The Paramedic and EMTs on Maui had recognized these needs and had initiated appropriate treatments. The neck spinal cord was protected by a cervical collar and the back spinal cord had been protected by using tape to secure him to the longboard.

They had started with the head. It had a piece of tape on the forehead which was secured from one edge of the board to the other. There was another piece of tape on the chin. It, too, went from one side of the board to the other. There were also sandbags on both sides of the neck at the ears. They were about a foot long and about eight inches around and weighed about four to five pounds each. These were the final adjunct to ensure the head did not move at all during transport.

The rest of the patient’s body was also secured to the board with tape over his shoulders, his chest, over his abdomen where his arms had been crossed to prevent movement, over his belly, over his pelvis, and over his upper and lower legs. There were two more sandbags on the sides of his feet and these, too, had been secured by tape. This man was one with the longboard.

All these precautions protected the neck and back spinal cords very well, but because his airway had not been protected with a tube into his trachea, there was still that threat of stomach contents being vomited up and then going into the lungs. If our patient did vomit, I would have to roll him and the longboard as one single piece onto his side to prevent that from happening. This would be a tough job to do in a small plane. Guarding the patient’s airway was the third full time job needing to be done during our time in the air.

This, then, brings us to:

Problem #5: Administration of two IVs

In one of the two IVs there was medicine treating the inflammation and swelling of the brain and the squashing for the brain stem. The other had just plain medical water. Again, it could be used as a route of administration for any additional medication needed by the patient. It was also available to support the blood pressure by adding fluids into the circulatory system if it was falling to a dangerously low lever.
In any given emergency, whether in an air ambulance or an ambulance on the ground, medications are always administered via the IV directly into the bloodstream. This is because when the body is “shocky” for any reason, it responds by constricting the arterial system thereby decreasing the flow of blood within that system. The body does this because it “reads” the scenario as a potential situation of bleeding and it attempts to decrease that bleeding by automatically constricting its arterial system.

What a wonderful piece of engineering this is that was done by the “Master Medical Engineer.” It kicks in automatically and prevents many deaths from bleeding. But, because of all that constricting, it is not appropriate in an emergency to inject medications into the muscle tissue. It just remains where it was injected because there is no way for it to be carried via the blood around the body. It must go into the IV for it to have the expected therapeutic effect.

Both these IVs could be susceptible to the movements of the air ambulance. Their flow rates could change dramatically or even stop completely, thereby altering the amount of medicine being received by the patient. They would need to be watched and adjusted constantly. This would be the fourth full time job needing to be done while we were in the air.

All this is what I encountered there on the apron of the Maui airport. The patient had an extremely critical head injury, two IVs, a heart monitor, Oxygen running, an unprotected airway, and three other life threatening medical problems, any of which could take his life on its own. I looked at the lead Paramedic and said, “we were not told about any of this. What am I supposed to do with this patient in the air all by myself.” He didn’t answer. Then I ask if he could send an EMT with us on the plane. To this he did respond and said, “we can’t do that. We are already short of EMTs today and need everyone to cover our emergencies here,” and that was that. Because this man needed to be on Oahu with the neurosurgeon a long time ago, we had to leave now. Right now. There would be no assistance from Maui emergency medical services.

I accepted the patient and replaced their airbag and mask with ours. The Oxygen tube was then detached from their mask and attached to ours. The other end was then detached from their Oxygen tank and attached to ours. We now had the patient fully supported with our breathing equipment. While the Maui EMT continued breathing for the patient with our equipment, they removed their cardiac monitor and I attached ours. The patient’s heart activity was now being monitored with our equipment.

Then, we placed him and the longboard to which he was attached onto our gurney and exchanged our longboard and sandbags for the ones from Maui, and gave them two unopened IV bags. The patient and our gurney were now ready to load into the airplane. In order for them to pass through the door, the foot of the gurney had to be tilted upward to about a thirty to forty degree angle. We were putting the gurney with the patient on it into the airplane foot first so his head would be toward the front. Everyone was needed to accomplish this task.

When the gurney was about halfway into the plane, one of the EMTs jumped in and opened the locks on the gurney floor mount. When the rest of it was finally in the plane and in place, we locked it to the floor. Meanwhile, the co-pilot was hanging the IVs from our IV poles and the pilot was placing the monitor in its holder and locking it into place. Next, he put the Oxygen tank into its holder and locked it in place. Everything had to be secured for the flight by locking it in place.

From the moment the Oxygen tube had been detached from the ground Oxygen to the time the gurney had been locked in place only about five minutes had passed. It was a very good transfer. Once all this was done, and as I continued to breathe for the patient, we began taxiing into our position for takeoff to Honolulu on what would turn out to be the most intense patient care experience I was ever to experience in my entire time as a Paramedic. On this case, I earned my credentials as a Mobile Intensive Care Technician, a Hawaii State M.I.C.T. Paramedic.

After accepting the patient, I had taken a position at the patient’s head kneeling on the floor. I had to be right near the head because the airbag sten attaching it to the face mask was very short, only a few inches. I planned on being there the entire flight. There was no way I would be able to sit in a chair and use a seatbelt.

As I watched the IVs and the heart monitor, I continued to use both hands to squeeze the airbag and to hold the mask in place over the nose and mouth. I also had to immediately check the blood pressure to obtain a “baseline” reading. This would be the value below which the blood pressure could not fall during the transport. To do this, I also had to use both hands. Of course, this was impossible, I didn’t have four hands. I needed a miracle and so did the patient. Then, and without me asking, that miracle suddenly appeared at my left elbow.

During our taxiing, the co-pilot had noticed what was happening and had informed the pilot. Then he had asked for permission to leave his seat so he might help. Without hesitation, the pilot said “yes.” The co-pilot was the first miracle of the Six Miracles in Paradise. We were a team, of course, on that air ambulance call and transport, but it was and still is my professional judgment he was the single reason our patient made it to Honolulu alive. I had the honor to fly with him and our pilot on many future missions, and I was always able to count on both of them. The three of us became a close team and were blessed to be able to save many lives.

I also know the two of them, the pilot and co-pilot, were the single most important factor enabling me to provide proper patient care in my year and a half on the air ambulance. Because of their willingness to help in every way on all the occasions I had asked for their assistance, not one of our patients died. All of them, one hundred percent, made it to Honolulu from all the islands with a blood pressure and a pulse. Some of them, just like the patient in this call, were also not breathing on their own, but they were alive and had a chance for recovery. I believe that achievement still stands today in 2019 as the record in Hawaii for successful air ambulance transports. In all modesty, I believe we were an exceptional air ambulance team.

As the pilot was taking off from Maui, I handed the airbag to the co-pilot and told him to squeeze it every four to five seconds. I also showed him how to hold the face mask in place over the nose and mouth. To do both these tasks, the airbag had to be pressed against the sandbag bracing the neck rather than squeezing it with two hands because the other hand was holding the face mask. In this way, the co-pilot was able to force air into our patient’s lungs. I explained to him he would know if he was doing it correctly by the rise and fall of the patient’s chest. This was the first and only time I had to show him this. He was a natural.

I then had time to check the IVs and found they had been altered by the dynamics of our takeoff. After adjusting them back to their appropriate flow rates I checked the blood pressure and pulse and it was fortunate I did. With the first reading, I found the blood pressure was below the baseline I had set on the tarmac at the Maui airport. I then checked the monitor and found the heartbeat pattern was changing in an ominous way. It suggested that if I didn’t correct the blood pressure very soon, it would continue to lower to a point so low I would have to begin CPR. This I did not want to do in a small plane flying over the Pacific Ocean. I had to raise it immediately. Right now.

The first thing I tried was to give our patient the maximum allowable amount of fluid from the second IV. I could only infuse that amount because if I gave him more it might raise his blood pressure too much and there was no way to remove it. He already had increased pressure in his brain, so this would not be a good thing.

I re-checked the blood pressure and found that the extra fluid had not helped. In fact, the blood pressure was now lower than it was just a few minutes before. This meant our patient was now in extremely critical condition. He was in danger of sudden death. Because of this situation, I radioed the ER at Queen’s Medical Center on Oahu and reported all this to the doctor. His order was for me to apply the MAST garment and only inflate the two leg sections.

The MAST garment is a “suit of clothing” which is made of a non-snag, nylon type material. It is divided into three separate sections, each of which is inflatable by using the blow-tube dedicated to that section. It resembles a pair waist high waders minus the suspenders which are worn by fishermen when they stand in a stream to fish.

The purpose of this “suit” is to cause pressure over the area(s) that are covered by the inflated section(s). In this way, some of the blood in a covered section is forced out of that area of the body and into the veins and arteries of other parts of the body, hopefully raising the blood pressure. This is the same thing I tried to do with the extra IV fluid except this effect is reversible by simply deflating the sections. There is no danger of increasing the blood pressure too much without being able to correct it.

As the co-pilot continued breathing for the patient and as I continued watching the monitor and checking the IVs in order to maintain their correct flow rates, the pilot continued to fly at about our top speed of one hundred and eighty miles per hour and only about five hundred feet above the surface of the Pacific Ocean. Due to the air currents coming up from the water, this low altitude and rapid air speed resulted in a very unsettled ride. Despite that ride, I was now required to unsecure our patient from the long backboard. This was potentially a very dangerous thing for our patient. One really bad bump might throw him off the gurney and end his life. Actually, for that matter, it could end all our lives. The doctor authorized us to do this only because the lowering blood pressure was a greater risk to his life than the risk of him flying off the gurney.

To do this, I had to untape the lower part of the patient’s body from the longboard so the legs were accessible. Despite the erratic movements of the plane, I had to do this without moving and injuring his neck or back spinal cord.

I began to take off the tape. When he was fully untapped and his spine was unprotected and subject to those erratic movements, the Oxygen ran out. I had to stop everything and change the tank for a full one. In our small aircraft, this was no simple matter.

The extra air tanks were locked in place in a cabinet that was also locked. With the co-pilot still breathing for the patient using just room air, I had to unlock the cabinet and unlock the tank we needed. Then, I had to pull it out to open a space in which the empty tank would be stored and locked in place. With the new tank loose on the floor of the airplane (a very dangerous thing) I had to remove the flow regulator from the empty tank and put it on the new tank and then lock that tank in place. The Oxygen delivery tube was still attached to the flow regulator and to the facemask. The patient was once again receiving pure Oxygen.

I was now able to store the empty tank in the empty space created by the removal of the full tank and lock it in place. Then I closed and re-locked the cabinet door and returned to the job of applying the MAST garment on the patient. During the exchange of the tanks, the co-pilot had been keeping the patient from moving by actually lying on his shoulders, chest and abdomen. I hadn’t told him to do it, he just did it on his own. His dedication to this patient was beyond all expectations. By this time his blood pressure was almost undetectable and his heart had begun beating in a very irregular rhythm. Our patient was dying.

The whole scene was a real “goat rodeo” happening five hundred feet above the Pacific Ocean, flying along at about five hundred miles per hour. But, because we had to, somehow we got it all done and the patient re-taped to the longboard. It had taken a very long ten minutes. Now, with the MAST garment in place, and as I continued to watch the monitor and the IVs, all I had to do was to inflate the two leg sections by blowing in the blow-tubes for each leg compartment. This proved to be a difficult thing to do.

As I blew into the first tube to fill the first leg chamber, I had to use big, full, forceful breaths because the tape holding the patient to the longboard restricted the expansion of the chamber. Also, because of the condition of the patient, I had to do it as quickly as I could. By the time I had finished the first leg chamber, my whole body was tingling from hyperventilation. I re-checked the blood pressure and it was up a little but still too low. Tingling or not, it was on to the other leg chamber.

Again, I blew as quickly and forcefully as I could. By the time the chamber was filled, I was so dizzy the co-pilot noticed and asked me if I was alright. I was so dizzy, I had to grasp the side rail of the gurney to keep from falling over while I was still on my knees on the floor.

Dizzy or not, I still had to check the patient’s blood pressure. To do this I would need to let go of the gurney railing and risk falling over. Because the co-pilot no longer needed to hold the patient onto the gurney, I asked him to move closer to me while he continued to breathe for the patient. With him close, I could let go of the gurney and lean against him while I used both hands to check the blood pressure. And so, he did, and so did I.

I found the blood pressure to be up enough to relax a little while the dizziness passed. After two minutes, I checked it again and it was still rising and the dizziness was gone. The patient was out of immediate danger. We were all amazed and actually cheered out loud as one. Even the pilot who had been listening from the captain’s chair, joined in the celebration. But, the cheering was short lived because I had to get back to the patient and his blood pressure. I had to make sure it was not rising too high.

If it was continuing to rise beyond the normal limits, it would have to be addressed immediately. The trick was to raise the blood pressure fast enough and just enough to keep him from dying, but not so much that I would “blow off the top of his head,” so to speak. This was no easy task in a normal emergency room on the ground, let alone flying along in this bouncing airplane.

I continued to check the blood pressure and for sure, it was climbing too fast and becoming too high. This is where the MAST garment was worth its weight in gold. All I had to do was to gradually deflate the leg compartments by equal amounts at the same time while continuing to check the blood pressure. So, I began to do just that and continued until the blood pressure was stabilized at an acceptable level. By this time, we were about twenty minutes from Honolulu and the co-pilot had been breathing for the patient the entire time without complaint or error. The man was “God-sent.” The rest of the flight was uneventful, and I was able to take over breathing for the patient. The co-pilot was needed in his chair for the landing.
When we landed, the patient was still not breathing on his own, but his blood was well Oxygenated, his skin was nicely pink, and he had a normal blood pressure, heart rate and rhythm. We had successfully done our part and given him a fighting chance at recovery. That was what my job was all about. It was now up to the ground ambulance Paramedic and crew to continue that success until the patient reached the emergency room.

After the ground ambulance left with our patient, the three of us just stood at the open door of the airplane in the silence of the moment, just being together with nothing to do. It was a heavy moment of disbelief that the whole thing was finally over.

I removed the medical equipment, supplies and gurney for their return to the company office. Then the captain and co-pilot, with the assistance of the airport ground crew, re-configured the plane cabin with its fourteen seats. There would soon be another, slightly different, charter assignment for it as it was used to fly tourists around the island. Life is full of contrasts.

Before I left for the office, I asked the captain and co-pilot if they wanted to join me for a Mai-tai at one of the beach-side resorts. I needed the peace of the ocean and the visual of the horizon to ease the tension I was still experiencing. They declined because they were still on duty either for the next air ambulance or for an island tour. I was done for the day.

Today had been my in-between-shifts day-off from the ground ambulance and I needed some down time. I drove to Waikiki, sat at a beach-side table by myself at one of the resorts and ordered that Mai-Tai. For some time I just sat there in silence until I noticed the sun had begun its downward arch. I had my regular twenty-four shift the next day starting at eight o’clock in the morning and I had to get up at six.

With a deep sigh I stood up, turned around and started walking to my car. Then, almost as an afterthought, I turned to look back and noticed that my Mai-Tai was still sitting on the table undisturbed. Almost an hour had passed and I had not taken one sip. Not one. It was still there in its original state with its salted rim, a sprig of green mint, a round of Pineapple with a maraschino cherry on a long tooth pic, a stir stick and a tiny colorful umbrella. I hadn’t touched it. (Why are Mai-Tais served with tiny umbrellas?) As the sun continued to set, I drove home to get ready to do it all over again the next day.

About thirty five years later, as I was surfing the internet, out of the blue came the message, “hi Lanny, remember me? I was the co-pilot on that air ambulance trip we did with the guy with the head injury from Maui.”

I was stunned, completely stunned. He went on to tell me that after many months in the hospital going through intense physical therapy, our patient actually walked out on his own and into an almost normal life. His survival and recovery were considered to be a true miracle. I did not know this because I had left Hawaii for a job in the Holy Land as a Paramedic. After that, I went on to other overseas positions traveling through forty five countries over the next twenty-four years. But that’s another story.

After all this time, it felt good to know that what we had done on that day in Paradise had made such a difference and we have remained in contact since our re-discovery of each other. Unfortunately, I have not been able to do the same with the pilot, and this is why.

After my year and a half staffing the air ambulance and continuing to work on the ground ambulances, I resigned as a Paramedic and accepted a position with the Hawaii State Department of Health as the ambulance regulations enforcement officer for the entire state. After doing that for some months, I was promoted to the position of Acting Program Officer in charge of the entire Emergency Medical Services System, EMSS, for the State of Hawaii. This included the air ambulance. It was quite an honor for a person who, only two and a half years earlier, had started out as a patient, bed-side aid at Mahelona Memorial Hospital on the island of Kauai.

About thirty days after accepting this promotion, on a stormy night, the air ambulance on its way to pick up a patient had flown into the side of Mount Waialeale on the island of Kauai killing all on board. There had been a different co-pilot on that flight thus, this man had not been killed. Also, because I had resigned just a few months earlier, a different Paramedic, not me, was killed.

Because I was then the EMSS Program Officer for the State of Hawaii Department of Health, it was my duty (I would have anyway) to attend the memorial service honoring all those who had died. For the whole time I was at the service, I could not stop thinking but for a quirk of fate, that service could have also been for me. I have attached my journal entries wherein I wrote about the air ambulance going into the mountain and then the finding of the bodies. It seemed important to me that I should include them here.

Epilogue

For you to have the proper perspective of this air ambulance call, you must know that thousands of ambulance trips, air or ground, happen everyday. However, this one was very intense and unusual. For it to have had such a successful outcome, a whole chain of medical events not only had to take place, but those events had to happen perfectly over a very long time. This patient wasn’t breathing on his own for over three hours. Over three hours!

Without doubt, the assistance provided during the transport by the co-pilot was the single most important reason our patient had survived to make it to the hospital. All the things he did for all that time surely saved this man’s life. The first miracle.

Before that, the people in the dive boat out on the Pacific Ocean off the coast of Maui had to safely, and without causing further injury, pull the man from the water. Then, instead of being distracted by the four gaping and bleeding scalp and skull wounds, they had recognised he wasn’t breathing and did the one thing that was really needed, mouth-to-mouth rescue breathing and it needed to be done perfectly.
This shocking scene had to continue for as long as it took the dive boat to return to the dock. Then, it also had to continue at the dock for as long as it took the ground ambulance to arrive. With incredibly professional foresight, the dive crew had radioed for an ambulance while they were on their way back to the dock. This saved a whole lot of time and without doubt contributed to the patient’s successful recovery. All these things done by all those people for all that time surely saved this man’s life. The second miracle.

After the patient was transferred to the Paramedic and EMTs with the ground ambulance, they immediately added Oxygen to the rescue breathing. It was at this point, the Paramedic had chosen not to insert the breathing tube into the patient’s lungs. He was then secured to the longboard with the neck collar and sand bags in place, and loaded into the ambulance. Because time is of the essence with an injury to the head that is or may be bleeded into the head, all other treatments were done while transporting him, CODE THREE, lights and sirens, with the initial destination being the hospital in Lahaina.

During the transport and while an EMT was breathing for the patient, the Paramedic had the time to do a definitive examination and to report his findings to the doctor waiting in the ER. After the report, the Paramedic followed the doctor’s orders not to bring the patient to the ER in Lahaina. Instead, he was to be transported directly to the airport where we were already waiting.

It was during the transport that the IV with the medicine in it to reduce the brain swelling was begun. They had also attached the cardiac monitor so they were able to see the heart activity in real time, and had inserted the second IV. It required about forty to fifty minutes at high speed to arrive at the airport with the patient.

All these activities and treatments by the EMTs and the Paramedic were done perfectly with complete accuracy and professional skill. I knew this was correct because when I received the patient on the apron at the Maui airport, all his needs had been identified correctly, treated correctly, and were being managed correctly, even if it was taking two EMTs and the Paramedic to do it. All these things done by all these people surely saved this man’s life. The third miracle.
You already know what happened after we received the patient. All those things done by us surely saved this man’s life. The fourth miracle.

At the airport in Honolulu the waiting Paramedic and EMTs accepted the patient. We once again had to exchange our equipment and supplies for theirs before they could transport him to the Queen’s Medical Center. This required less than five minutes. During that transport at CODE THREE, lights and sirens, they continued his rescue breathing and other treatments and they all had to be done perfectly. Upon arrival at the ER, the patient’s condition was still extremely critical, but he was stable, well Oxygenated, had a good heart rate and rhythm, and had a blood pressure in the normal ranges. All the things done by all those people in the ground ambulance surely saved this man’s life. The fifth miracle.

In the emergency room at the Queen’s Medical Center, all the techs, nursing assistants, nurses and doctors continued the patient’s treatments. The first thing done was for the doctor to insert a tube into the patient’s airpipe and lungs. Finally the patient’s airway was protected. Following that, an automatic breathing machine was attached. This replaced the people who had been squeezing an airbag to breathe for the patient for more than the last three hours. Then he was taken to imagining for the CT scan of his head.

At the time of this emergency, a CT scan took a long time and the patient’s head had to be inserted deeply into it. As a result, the automatic breathing machine had to be detached and the bagging re-initiated for the duration of the scan. Additionally, several of the other treatments had to be monitored or continued by hand during this time and they all had to be done perfectly.

To do all this, everyone involved had to stand very close to the machine and therefore had to be protected from the “x-rays.” This involved some danger to the medical staff and a tremendous amount of preparation and time. All these things done by all those people surely saved this man’s life. The sixth miracle.

Following the CT scan, the patient was re-attached to the breathing machine and taken back to the emergency room to be examined by the Neurosurgeon. From there, he was escorted to the operating room by the surgeon where he finally received the definitive surgical care he had needed since his injury happened over four hours earlier. The operation required four more hours and had to be done perfectly to stabilize the patient. Four more hours! All these things done by all those people surely saved this man’s life. The seventh miracle.

From what I have described here in this epilog, you can tell that what we did in the air ambulance, despite how dramatic it might have seemed at the time, and it was, was only one part of this man’s care. There was a whole chain of medical, life saving links that worked together successfully in teamwork to enable the patient to walk out of the hospital and back into a normal life. This, of course, was The Final Miracle in paradise.

I remain satisfied and very pleased to this day that our team of a pilot, co-pilot and me, a Paramedic, was one of the links in that chain of miracles.



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