First Flight Pacemaker

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The Emergency Medicine Residency Program (ER Resident) at St Vincent’s Medical Center/ The Toledo Hospital in Toledo, OH was three years duration. The first year was spent among various medical specialties (Pediatrics, Surgery, Internal Medicine, OB/GVN, etc.), learning hospital medicine from the major specialties. The final two years were spent in the Emergency Department and on various critical care rotations. At the start of the second year, select PGY-2 residents (post graduate year-2) were permitted to fly on the helicopter.

Life Flight was the aeromedical transport helicopter that served the northwest Ohio region. The helicopter transported critically ill patients between hospitals and responded scene runs to treat and transport car crash victims. The crew consisted of a pilot, a flight nurse, and an Emergency Medicine Resident. The SVMC/TTH Emergency Medicine Program was different in that second- and third-year residents helped staff the helicopter. It was one of the few programs in the country that did so and was a major attraction for residents. The resident had to have approval from the attending staff prior to becoming approved to fly.

Luckily, I was approved at the start of my second year. I learned from previous residents that the flight nurses were the best of the best. These nurses were full-time flight nurses. They dealt with critically ill patients and dangerous situations daily. They had the knowledge to treat critically ill patients while dealing with residents of various abilities.

My first flight shift was with the infamous flight nurse nicknamed, Flightnick. She had years of experience and had even survived a helicopter crash two years previously that resulted in the death of the pilot and the Emergency Resident. Her reputation was of superb capabilities and high expectations. She was critical of all the residents. I knew that I needed to gain her confidence as I would work with her for the next two years.

Our first flight was to transport a female patient with an acute heart attack. She was at a small hospital Emergency Center in southeast Michigan and was to be transported to St. Vincent’s Medical Center in Toledo for further care.

Upon landing and evaluating the patient in the Emergency Center at the outlying hospital it was apparent that the patient was not ready to be transported. The patient had a heart attack and had an IV drip of Lidocaine. This was the accepted practice at that time. Lidocaine was used to decrease the possibility of ventricular tachycardia (rapid, abnormal heart rhythm). The staff at the outlying hospital would start the Lidocaine and the patient would develop bradycardia (abnormal slow heartrate) and would drop her blood pressure. They would then stop the Lidocaine and the patient would develop Ventricular Tachycardia. This cycle repeated over and over.

After examining the patient, I looked at nurse Flightnick and said, “She needs a pacemaker.” Flighnick immediately started prepping for a central line. Back then, a temporary pacemaker was accomplished by inserting a central line (IV into a deep vein under the collarbone). Now days central lines are done with the help of an ultrasound machine. Back then, it was done blind. One would find the landmarks and insert the needle where the vein was supposed to be. Often, this required “fishing” for the vein and risked the complication of dropping the lung. An intravenous pacemaker required placing the central line and then inserting the pacemaker electrode through the IV and advancing it until it reached the ventricle of the right side of the heart. The location of the electrode was determined by watching the patient’s rhythm strip. I had never floated a pacemaker.

Thankfully, I hit the Subclavian Artery on the first attempt and floated the pacemaker without a hitch. The Lidocaine was infused, and the patient’s heart rate was controlled with the pacemaker. The patient’s blood pressure stabilized, and we were able to transport her without incident.

First impressions with nurses are huge. After that flight, Nurse Flighnick and I worked as a team for the next two years.