or  on  my  blog:    MitchelMD.com    

 The  following  is  an  excerpt  from  50  Flights:  A  Physician’s  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  I’ve  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  

son’s  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  child—battered  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,  it’s  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.