E jection D e c i s io n The pressure to continue a life-saving mission can be overwhelming. When the stakes are high but the risk is higher, how do you make the decision to abort? By Dan Foulds I t was the last hour of the last night of a week’s worth of work. I had rolled out of bed, cleaned up, straightened up, and was making cof- fee. A week off beckoned. In my mind, I was already on the boat. Alert tones sounded across all three radios in our quarters. “Crap.” I listened to the scene-flight assignment, and told the comm-center I would check weather. I didn’t want to go, but the ceiling and visibility weren’t bad enough to get out of the flight. The forecast was okay. No mention of fog, but we had a conjoined temperature and dewpoint. “Base, LifeStar responding.” My nurse that morning was Jillian. She is a veteran of trauma-centers in South Africa. Real trauma centers. Don was the medic. We had worked together for a couple of years. I had helped him work on dead people, who then proceeded to be undead. We had a bond of trust. He had skills. I had skills. We liked each other. We headed northwest from Savannah into the country. Once you cross I-95, it’s a different Georgia. Rural. Two-lane roads. Pastures and plows and pine trees. Daylight was fresh upon the world, and the air was still and heavy. The vents for the air conditioning were streaming a cool, moist fog; the system in a BK117 cools the air, but doesn’t remove moisture. The air outside was saturated, but still clear. Heavy gray clouds hung low overhead. “At least it’s daylight...” Thirty miles northwest and we came to our scene, a country cross- road at which a truck and car had arrived simultaneously, neither stop- ping. The truck won. I got the landing zone briefing over the radio, did a recon, and landed in a field. My crew tromped off to get the victim. I started working on forms. Don came back. “Can we take two?” “What’s their total weight?” “400.” “Yes.” “Okay, it’s going to take a few minutes — the lady is entrapped pretty badly. These people are circling the drain.” “Roger that.” I set up the GPS, and entered frequencies into radios. I called the comm-center and advised “two patients, both trauma-alerts.” After a 20-minute delay, the procession headed to the helicopter: fire- fighters, medics, and my crew — one per patient. We loaded with the engines running, and after the helpers were clear I advanced throttles and asked for the before takeoff checklist. 34 Ver tical 911 Maga zine Don called off the checks. I responded and asked him to clear us left, right, and overhead. We blasted off. As soon as I cleared the trees, I could see tendrils of mist coming up out of them. The atmosphere had become sufficiently saturated to produce fog, and it was happening rapidly. I was now in a race. I could hear Don and Jill working, talking about what to work on first. Blood was coming from multiple injuries. They were very busy. I gave a short report to the comm-center and said that the crew might be too busy to call. “Please have help at the heliport.” As we neared the coast, the visibility got worse. I began to feel the gut-ache of pressure. I heard a Delta pilot tell Savannah that he needed to hold west of the airport for some weather. “Crap.” I called Savannah approach, used “Lifeguard,” and asked for direct routing to the hospital. The weather got worse. The patients got worse too. I could hear fatalism in the crew’s voices. Then the voices in my head started. “Go faster. Faster. You have to get them to the hospital — now!” This was countered with, “The weather is going south. You need to stop somewhere — now.” We rolled across I-95, and I changed to the tower frequency. The tower controller announced two miles of visibility and said, “What are your intentions, LifeStar?” “I need a special VFR clearance across the airport at 500 feet, I have two crash victims on board. I am trying to get them to Memorial.” I was totally caught up in the drama. Patients dying. Not enough weather. Not enough time. No good choices. What to do, what to do, what to do? I was in a “naturalistic environment.” These require “naturalistic decision making.” Making choices when a lack of time to think is coupled with extremely high consequence is hard. It’s excruciating. My crew and I and those two dying patients? We were between a rock and a hard place. I could sense that I wasn’t making good decisions. Human factors were working against me. We blew across the runways at Savannah International. A safe landing was right there for the taking. My head said, “Land! Call for an ambu- lance. Stop!” My heart said, “They will die.” I was very uncomfortable. I called the comm-center to update them. Jill could hear the anxiety in my voice. She said, with her accent, “Daaan, you are doing a wonderful job...”