A Final Arc of Sky

By Ashley Neglia

After 20 years as a pediatric and neonatal intensive care unit nurse, Jennifer Culkin traded the ICU for the rear of an Agusta A1091 -- the helicopter that became her emergency room. With a nursing career that spans 30 years, she has witnessed and participated in not only the beginning but also the end of life. She has not only cared for her ailing parents, but struggled with her own diagnosis with multiple sclerosis. She has lost friends, colleagues and patients and gained a lifetime's worth of experiences that she recounts in her memoir, "A Final Arc of Sky." In an interview with AOL Health, Culkin describes what challenges she faced, both physically and emotionally, as an emergency flight and critical care nurse.

AOL Health: How do you handle the pressure and stay calm when you're working?

Jennifer Culkin: There's a certain amount of compartmentalization that you have to do. You have to stay in the moment, you have to stay focused. You can't allow your feelings to get in the way if your effectiveness. You have to be the sort of person who can put feelings aside and focus. That's a skill I think you can also learn. I think people develop that over time. Knowledge helps you. The more experience you get, the more you learn. In nursing and in medicine it's a lifelong learning process.

AOL Health: Even with preparation and experience under your belt, are there ever moments where you get scared or frightened?

Culkin: Oh sure, absolutely. I think what happens for me is that when I start focusing on the first thing I need to do then it flows from there. You become more focused and you have less room for feeling nervous and fright. There's certainly some of that involved. Your heart rate definitely goes up at times.

You do have to react and when something comes at you out of left field when you didn't expect it. It's like, oh shit, and you have to refocus yourself. I think part of it is accepting that being afraid is part of it. It's normal and natural. Your feeling of initial fright is natural, but its' keying into what's the first thing you should do, and you become skilled at that overtime, especially if you're faced with it everyday. It becomes much more commonplace. It has to be something really extreme to freak you out.

AOL Health: Can you describe a time when a situation really did freak you out?

Culkin: You are responsible for a fellow human being; you want him or her to live, not only to live, but to thrive. You want the best possible outcome, but you don't have all the resources of a medical center. You have two brains and the contents of your bags. Have you analyzed the situation correctly? Do you have the skills? Will you make the right decisions? Can you make the difference that will get the person to the hospital alive and neurologically intact?

For me the very scariest flight was the first chapter in the book, actually, "The Shadow We Cast." We were transporting a gentleman in his forties (younger than I was, and with several children at his bedside) with an aggressive cancer and upper gastrointestinal bleeding, flying him from a small rural hospital to a large referral center. He was awake, alert and talking to us when he suddenly lost consciousness, blood pressure and heart rate due to massive hemorrhage, most likely from a vessel in his esophagus. We were in the air, many, many minutes out from the receiving hospital. When he started spitting blood at the window of the helicopter, a second or two before he rolled back his eyes and passed out, I just had time to think "Oh, sh**…", a sentiment that sank all the way into my core. I felt the same stab of fear-related nausea that strikes people with normal jobs a second before they rear-end the car in front of them; a sick sweat broke out under my flight suit. After that, my partner and I had to run a full resuscitation and I think we both moved into a state of focus in which fear was still hovering under the surface but it played less of a role. We started with the first, obvious actions and everything flowed from there -- experience and training informed what we did. And I believe we did everything possible, but in this case it wasn't enough. I still regret that we couldn't make the difference for this relatively young father.

AOL Health: Have you ever had helicopter-related troubles?

The other variety of fright is when things go wrong from the aviation standpoint. I've had friends and colleagues who lived through bird strikes that shattered the windscreen and splattered the interior of the helicopter with bird blood and remains, others who survived "hard landings" and crashes. Four friends have lost their lives in crashes. (Some of these incidents are in the final chapter of the book: "Out There in the Deep.") I was lucky that way -- my scariest moment was tiny by comparison.

We were on final approach to an accident scene. I could see the landing zone -- it was a well-lit nimbus in the dark, and large enough, but the area was so remote and heavily-wooded that there was nothing but a black void all around it. Our pilot asked us to watch for obstacles as we descended and all of a sudden I saw and blurted out that there were trees right under us! Our pilot was great; the helicopter halted its descent before the words were completely out of my mouth, hovered in place for a second, slid over to the right into the clear, and we proceeded to land and pick up an intoxicated gentleman with a head injury and a probable pelvic fracture.

AOL Health: Because your job comes with such a high stress level, did writing become a kind of therapy for you?

Culkin: Writing does help me clarify. It starts out that I have this feeling in my gut about it, and I don't really know what the component parts of it are. But when I start writing about it I can tease out exactly what was going on and the dynamics. It's personally helpful in that way to help get your head on straight. I do have a journal, and I've always been a writer in a way. I started writing about things that had caught in my memory for one reason or another -- people and cases that stuck with me. In the process of figuring out why they stuck with me a lot of the book happened.

AOL Health: What made you want to become an emergency flight and critical nurse?

Culkin: I was an emergency flight nurse for five years and currently back in critical care. I was always interested in medicine, and I was always drawn to the higher tech, sicker patients. That's what attracted me to it in the first place, and now it's been 30 years. I think what is perhaps a little unusual about me is that I've worked in all the critical care specialties. I was a pediatric and neonatal nurse for 20 years and a flight nurse for five years.

AOL Health: Caring for sick children in neonatal and pediatric seems like one of the more difficult specialties to cope with emotionally. What made you want to go into it and how did you handle the children and their families?

Culkin: Basically, you're there to do what you can to improve the situation. I loved working with kids and families. Kids are so resilient. They're very courageous in a lot of ways. In pediatrics, the family is a constellation, so I really enjoyed doing that.

I like working in depth. I like the level of detail and the degree of understanding you have to have of complex issues when you work in critical care. I've enjoyed all the areas. With kids it was hard at times, but also when they improve they really improve. They can go on to live a long life, and that's very satisfying.

AOL Health: You've lost patients and friends, and I know you write about many of those experiences in your book, but what are some of the moments that have stayed with you over the years?

Culkin: There are quite a few. It's interesting because in the process of writing the book, I rediscovered some. You know, you take care of so many people -- I've estimated it's between 5,000 and 10,000 people now -- and it's interesting what little details will trigger memories.

When you lose kids that stays with you. I don't know the end of the story of a lot of the people I've take care of. When they leave the critical care unit I don't know whether they did well or didn't do well, so that's a hard thing.

One of the stories in the book is about the first baby I ever took care of that died. She had a congenital anomaly that was incompatible with long-term life. It was just being new at it, being new in the environment and taking care of her. I really bonded to her in the way, so she has stuck with me all those years. Another one that's in the book is a 17-year-old -- when you go out and get trauma in the field and they've had a cardiac arrest in the field from trauma, they're very unlikely to survive even if we transport. And so you go out and you pick up these people, and you know it's a little bit of a fruitless exercise. That's kind of hard. There have been quite a bit of those over the years.

People who have done well [stay with me]. I took care of a lot of babies with cardiac defects, and a lot of them went onto do very, very well even though they were really sick as newborns. There's a tremendous number of those.

Now in my current environment I'm on the other end of the lifespan with adults, very, very many elderly adults. It is really great when an elderly adult comes in and you can get them back to their baseline so that they can get to go home and have another while to enjoy their lives.

AOL Health: Both of your parents have passed away, and in the book you talk about caring for them as they got older. You knew exactly what was going on with them as a nurse. Was it difficult balancing being a daughter and a nurse?

Culkin: It puts you in an interesting position because you're usually the interfaith between the healthcare system and the parent for your family. That was kind of rocky in my parents' case, especially in my dad's case because he rejected a lot of the possible help he could get from the healthcare system. I had to work it out between him and me how much of that kind of help he wanted and at what point to back off. He has self determination. So that was very poignant and difficult, and at the same time I think we all did the best we could. It's a scramble for any family in that situation.

It was really trying to decide how much information and intervention my dad wanted or didn't want. It was particularly hard for me because had he been willing to go through more, I think he could possibly have had more good time, but he decided against it and you're the boss of your own ship in that way. He passed away in 2003.

My mom had been sick a long time, and for her it was a question of without too much guidance from her. She was queasy about medical details. She was an example of someone who didn't want to know. I would try to have that discussion with her. How much intervention do you want? What constitutes quality of life to you? And she just wouldn't play ball. Then I found myself in the position of having to decide for her how much was enough. She passed away in June 2002.

Continued: From Nurse to Patient -- Managing Multiple Sclerosis

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