ANGELS IN THE SKY

“I still get butterflies when the tone goes off, even after 15 years,” says Nathan Morreale, chief flight paramedic. When it’s his station, “you feel the tension ramp up. You’ve got 10 minutes to take off.”

Or, as flight nurse George Jan puts it, “It’s game face.” He’ll grab the blood from the fridge and time-stamp it, while paramedic Steve Conger helps the pilot finalize information for the flight. They are expected to be off the ground within 10 minutes of receiving the assignment from Flight Center at University Hospital. “You can’t rush, otherwise there’s a chance of missing something,” Jan says. “But you can’t dilly-dally either. There’s a sense of deliberate urgency; this is never the small stuff, it’s always urgent, critical, life-saving.”

Each of the bases can reach University Hospital's helipad within approximately 20 minutes. But AirMed is not simply about flying a patient to the trauma 1 center to get them state-of-the-art care. It’s about providing that same quality of care in the field and in flight while in precarious, cramped quarters where anything can and does go wrong. And to do that, you need crews who are typically alpha-type personalities, who thrive on autonomy and adrenaline. It can be tough to survive otherwise.

In AirMed’s ranks, you’ll find ex-NFL footballers, a former TV show assistant director, ice-mountain climbers and adventurers, sky divers and international surfers, and they all have one thing in common: they are operating at the top of their medical license. Flight nurses require a minimum of five years’ experience in the ER and ICU at a trauma 1 facility, while flight paramedics need five years with a high-volume 911 service. They have a wealth of state-of-the-art equipment and training to draw on to treat emergency burn patients, cardiac arrests, trauma, neonatal, pediatric, and high-risk OB/GYN cases. Ultimately, it’s their finely honed instincts and independent spirits that are the true cutting edge of their service. Making life-saving decisions under intense pressure in the most confined of spaces as turbulence shakes the helicopter’s frame requires nothing less.

Hospital employees regularly see an AirMed crew of flight nurse and medic, perhaps a respiratory specialist or flight physician, sauntering back post-mission through corridors, their equipment on their gurney, after yet another high-octane, patient-in-dire-distress delivery. But few understand what sets AirMed staff apart, says medical director Eric Swanson. “I can’t underestimate how cool it is to get into a helicopter, fly wherever it is, and take care of the sickest of the sick.”

With such privilege inevitably comes so much responsibility, so much weight on their shoulders.

When it comes to patient transportation from one facility to another—typically to University Hospital—the flight nurse takes the lead. But when the call is to a scene—a car crash on a highway, an accident in the mountains, a hurt child in a rural county—that’s where the paramedic shines, says flight nurse manager Deborah Witte.

Each has their pre-designated roles along with the need to always be communicating with the rest of that day’s allotted team, whether it’s an odd word because they know each other so well or more substantial back-and-forth when they are new to the flight crew. Teamwork is crucial. “We fly into the scene, we’re talking to each other about the information we have, about who’s giving meds and who’s intubating, who’s doing what on the aircraft,” Witte says.

The core team of paramedic and nurse need to be seamless. “We function best as equal team members,” Witte says. “We’re a continuum of patient care focused on the best patient outcome.”

And it’s not just the 112 nurses and paramedics. There’s a 36-strong pilot and mechanics team who work for Metro Aviation under contract to U of U Health. The pilots fly seven helicopters and two airplanes. AirMed’s vehicular assets reflect a reality few air ambulance services face nationwide, which is the enormity of their service area. It covers not only Utah and Wyoming, home to the seven bases, but also Nevada, Colorado and Idaho. It can mean fighting to keep a patient alive for sometimes as long as two hours.

Their distinctive University of Utah colors of red, black, and white flash in the sun as they fly over Salt Lake Valley or out to rural communities, rushing highly specialized health care not available in regional hospitals. To tell the story of AirMed is to recognize the tragedies of the past and the safety culture that grew out of them, and the remarkable individuals who wear with pride and humility the AirMed logo on the back of their fire-retardant suits. For veteran AirMed nurse Janie Ford, her vocation has been an honor to pursue.

“As long as the first call isn’t a teeny tiny baby, I’ll be OK,” he told himself.

His first solo shift was at night. The hours went by without the crew receiving a single call.

Then the beeps sounded.

“We’ll accept,” the pilot told flight control. How much did the patient weigh, the pilot asked? “Four kilos,” he said, jotting it down.

Volz was taken aback. The patient was a critically ill four-week-old baby. As the helicopter took off, his silence spoke volumes to his partner who told him over the intercom, “We’re going to be fine. Just don’t run away. We’ll make it work.”

Despite his nerves, it all came together for Volz with the support of his crew. “That night taught me a lot. You can work through it. Right off the bat, it taught me you have a partner, you’re a team, you work together.”

That working together requires intensely focused communication between crew members. Back when AirMed crews totaled just eight employees, it was a tight-knit family where a nurse and a paramedic knew what the other was thinking without having to ask because they worked together so much. As AirMed has grown to a roster of 30 nurses and 40 paramedics (many of them part-time), 16 specialty team members such as an OB perinatologist, along with another six or 10 respiratory therapists, the guarantee of working with crew members you have a relationship with—with whom you can communicate using only sound bites—becomes rarer. Reading body language and knowing how your partner thinks without having to ask isn’t always possible, so sometimes verbal communication has to come to the fore.

That’s just one reason why communications skills are so important for nurses.

When a flight nurse arrives on-scene, a key part of what they do is outreach and PR, says veteran AirMed nurse Janie Ford. “You can lose business so quickly if you snap at someone. It’s so easy to say the wrong thing.”

Veteran AirMed paramedic (and now retiree) Brent Speirs emphasizes that the ground paramedics who greet the AirMed crew at the scene are part of the team. “Nobody can give a better history than the paramedics on the street, so our philosophy is to work with them as a team.” At the same time, there can be a lot of politics involved. “You have to play well with other people out there,” Ford says.

Deborah Witte fell in love with the idea of becoming a flight nurse while working on an episodic TV series. The registered nurse graduate had worked in the University Hospital float pool for three years when her aunt, a writer and producer for CBS and Hallmark, was looking for a medic to work on the set of “Touched by an Angel.” She lasted six months as on-set medic, a role the passionate skydiver quickly learned would not test her mettle the way she had hoped. She wrangled her way into jobs as runner, gopher, and then production assistant. After nine years with the show, the 27-year-old had risen to assistant director. While filming an episode starring country singer Travis Tritt, a scene called for a boy to be flown to the hospital. It was shot at the Salt Lake Regional helipad, and as she watched the helicopter land and the crew jump out, she thought, “You can fly and be a nurse? This is what I want to do.”

AirMed program manager Frankie Toon argues that what makes a good flight nurse are qualities of resilience, compassion, and the ability to bring calm and knowledge to a chaotic situation. “You have to be able to deal with a variety of situations and think through not only the care of the patient but a host of other potential scenarios.”

Paramedics’ pre-hospital experience means they are used to adapting to fluid situations on the street. But for nurses without such experience, AirMed can be a challenge. If things go south, a nurse can’t ask another nurse to watch her patient while she takes a moment to adjust, Toon says. “If the weather goes bad and you can’t complete transportation; if there’s a mechanical issue with the helicopter; if the patient’s condition changes, you can’t let those things startle or affect you. You have to push on. ‘OK, we’re not going to make it to University Hospital. We’ll go by ground.’ Or: ‘Oh no, the patient isn’t breathing, we’ve got to intubate her on the fly.’”

Veteran flight nurse Lisa Brasher argues that you can never know everything. In the first years of flying with AirMed, there was an element, at least for her, of sometimes simply trusting your instinct, regardless of your specific knowledge level. “The thing that is scary is that you have so much responsibility, you have to know a lot about a wide range of things, that even with a background in the ICU and ER, you’re certainly never ready for everything.”

Which is why part of meshing with AirMed’s culture and personnel is having self-confidence. “If you walked into any situation and they saw doubt on our faces, they’d never trust us,” Volz says. “We’re asking facilities and families to just trust us.” AirMed crews, he argues, draw some of that confidence from looking at the big picture, both literally and metaphorically, of the thousand-foot view from above and bringing a sense of calm and distance to the situation.

Self-confidence is still a line to be trodden carefully. The more experience Brasher gained, the more she realized she didn’t know. And it scared her. “If you ever feel too confident in yourself, you’re going to get burned. We all like things to go really well, but in this job, they don’t always go that way. You have to be able to adjust. It’s been a learning curve that’s taken years.” With a laugh, she adds, “I think you kind of fake it till you make it.”

Part of that learning curve is lessons learned the hard way, such as the need to always check post-flight or pre-flight that every single item needed onboard is present, correct, and in working order.

Brent Speirs only became a self-described zealot checking the helicopter for every single item of equipment after being on a transport from Rock Springs. A monitor’s battery died and there was no replacement. “There’s not a worse feeling in the world than to go on a flight thinking you had every piece of equipment and you ended up not having it,” he says. “I got in the mindset as soon as the team briefing is over, I check all of it, alone, for 1.5 to 2 hours.”