An unpublished, fictional short story by Daniel E. Tyler; © 1993
It was pleasant and clear that early afternoon in Sydney. The gentle south west breeze raised barely a ripple for the dozen or so yachts and half-cabins that motored slowly up Berowra Creek -- their occupants looking forward to a lazy late Sunday lunch at the Berowra Waters Inn. For 15-year-old Brett McLeod and his schoolmate, Gavan Jamison, the second day of the June long week-end was to be peaceful and hassle-free.
The two boys had ridden bikes down to the Berowra Valley Bushland Park, planning to follow the Benowie Walking Track and then climb down the steep sides of the valley to reach a cave one of their school friends had told them about which was located a few hundred metres north of the Berowra Waters Road. As they passed the camping and picnic area at the eastern terminus of the vehicle ferry, they were blissfully unaware that this idyllic early winter afternoon would contain for them more drama than they had known in their combined lifetimes.
About 300 metres north of the punt, the walking track that follows Berowra Creek diverges uphill away from the creek. Searching for the cave they had been told about, the boys left the track on the western side and traversed a narrow sandstone ledge about 9 metres above a steep, wooded slope that runs down to the water's edge some 40 metres to the west. It was at that point that a piece of sandstone crumbled beneath Brett's sneaker and sent him crashing headlong onto rocky rubble at the base of the cliff.
Instinctively, Brett thrust out his hands and felt a sharp pain in his wrists before everything went grey. His fall was deflected by a sandstone outcrop halfway down the face. Gavan gasped in horror at the sickening thud and looked down to see his mate sprawled on his back across a large flat rock -- a pool of blood forming near his head.
Gavan scrambled back along the ledge, down the steep slope and across the rock rubble -- in less than a minute he was at Brett's side. It was 2:14 p.m. Gavan had no first aid training, but he knew Brett had been critically-injured. Most obvious to Gavan was the sharp bone protruding through Brett's blood-soaked blue jeans over his left shin. His left foot was twisted grotesquely at almost right angles to his leg. Both wrists were badly disfigured and both bones in his right forearm were obviously broken. Most of the blood on the rock came from a deep gash starting at the hairline just above Brett's right eye and merging into a pale bluish bruise over his right temple -- barely visible through the blood.
Invisible altogether, an artery supplying the brain's protective covering was ruptured. Every beat of Brett's strong young heart pumped blood out of the broken vessel and into the space between his skull and the outer lining of his brain. Inconspicuous and sinister -- this growing mass of blood pulsed silently like a time bomb threatening to end Brett McLeod's life prematurely. As Gavan came to grips with what he was seeing, he became aware of Brett's slow and laboured breathing. He spun around and sprinted back toward the Punt. The race to save Brett McLeod's life -- a battle which would directly involve over 60 people -- had begun.
The proprietor of the boat shed and kiosk on Berowra Creek knew by the look on Gavan Jamison's face that this was no hoax. He quickly dialled "Triple-O". A female voice answered "emergency" and the kiosk-owner asked for the Ambulance. The operator at Central District Ambulance Headquarters hurriedly noted the details onto a form and dropped it onto a high-speed conveyor. In seconds, it came to rest alongside the Channel 5 radio controller who co-ordinated ambulances throughout the Northern Suburbs. Scanning the information on the form, he yelled across the room to the Control Room Supervisor (also called the Senior Operations Officer -- or "S.O.O."), who dropped his paperwork and strode across to the Channel 5 controller's console. It was 2:24 pm. Already 5 people had become directly involved in the rescue operation.
Handing the Supervisor the form, the controller was on the phone to Gosford Control, requesting the General Duties Car from Hawkesbury River Station be despatched. He hung up and dialled the St. Ives Ambulance Station, despatching their paramedic car. Back at his desk, the Supervisor picked up a white phone. There was no need to dial. Within seconds a voice said, "Police Here," and a second later another said "Fire Brigade Here." Identifying himself, the Ambulance "S.O.O." spelled out the information to his counter-parts in the other services, advising them that he had already responded paramedic and general duties cars and that he was about to despatch the CareFlight Helicopter to the scene. The closest designated rescue unit to the location was the Fire Brigade Unit at Berowra Station, only a few minutes away. It was decided by the representatives of the three services that Fire Brigade would respond their Rescue and Salvage Unit from Berowra, but that Police Rescue Headquarters in Zetland would be placed on stand-by in case specialised cliff rescue expertise or equipment was needed. All three supervisors then hung up their "Bat-Phones". It was 2:27 pm.
The ambulance supervisor then pressed the button labelled "CareFlight" on his auto-dial. The phone rang twice and a voice answered, "NRMA-CareFlight Emergency, Duty Pilot speaking." As the ambulance supervisor spelled out known details of the job, the pilot covered the mouthpiece of the phone and yelled, "cliff rescue, Berowra Waters, multiple-injuries, unconfirmed" to the crew who had gathered in the hangar just outside Flight Operations. The pilot took details of the location and gave an ETA of 2:44 pm.
Meanwhile the rest of the helicopter crew -- doctor, paramedic, and rescue crewman -- had placed a rope pack on the helicopter alongside the basket stretcher that was already in place. The doctor then made a quick call to Westmead Hospital Blood Bank before sprinting across the cricket oval to the hospital to pick up the "blood bucket". The crewman and paramedic moved the helicopter out of the hangar onto the helipad and the pilot removed the "Cowan" 1:25,000 topographic map from the map rack on his way out the door. By 2:34 pm the CareFlight Twin-Dauphin helicopter with doctor, SCAT Paramedic, Rescue Crewman, and Pilot plus Rescue and Medical Equipment and 6 units of universal donor "O-Negative" blood was lifting off the pad at Westmead and accelerating across the top of Northmead on a direct track to Berowra Waters.
Having made the "Triple-O" call, the kiosk owner suggested that young Gavan Jamison seek help from the local bushfire brigade which was conducting an off-season training session in the fire hall at the northern end of the car park. Gavan rushed into the hall, nearly stumbling over a group kneeling in a circle on the floor around a "Resus-Annie" upon which one of their members was practising Cardio-Pulmonary Resuscitation. Having breathlessly explained about Brett, Gavan then set out with four of the volunteer Bushfire Brigade personnel -- the Brigade Captain, the first-aid instructor, and 2 others plus a first-aid kit -- along the track toward where Brett lay.
At Police Headquarters, the Duty Operations Inspector (or "DOI") finished his call to the Special Operations Group at Zetland and walked across the radio room to the "E"-District operator. A call went out for any car in the Berowra Waters vicinity to attend the location and advise details. "Berowra-Two" acknowledged with an ETA of 4 minutes. Back in his office, the "DOI" phoned the Water Police Headquarters and arranged for Police Launch Brooklyn to attend Berowra Creek to provide water access if necessary. He then placed the Police Air Wing on notice that one of their helicopters might be required to fly personnel and equipment from Zetland to the scene. He also phoned the "E"-District Acting Commander to inform him of the operations within his area.
At 2:35 pm, with lights flashing and sirens blaring, the Fire Brigade Salvage and Rescue Vehicle manned by the Berowra "B" Platoon turned into the boat shed car park and pulled up outside the local bushfire brigade headquarters. "Berowra-Two", with two Police constables pulled up and parked alongside. 4 of the 5 fire brigade personnel filled a basket stretcher with ropes, carabineers, harnesses, blankets, and an Oxy-Viva and, led by a bushfire brigade volunteer, set out in a northerly direction along the walking trail. One police constable, armed with a portable radio, accompanied them. The other remained with his vehicle and notified "VKG" (call sign for Police Radio Room) that the bushfire headquarters car park would be a suitable staging area for rescue operations.
At that precise moment, the Hawkesbury Ambulance with lights and sirens was winding its way down Berowra Waters Road, the St. Ives Paramedic car was accelerating north along Pacific Highway past Hornsby, Police Launch Brooklyn skimmed up the Hawkesbury River with 2 water police constables on board, and the CareFlight helicopter thundered over Pennant Hills 1000 feet above the roof-tops at almost 4 kilometres per minute. Twenty-three minutes after Brett had fallen 9 metres onto rocks at a difficult bush location 30 kilometres north west of Sydney GPO, 29 people had already become directly involved in efforts to save his life -- efforts which at that stage were by no means assured to succeed.
The first thing that Gavan noticed as he reached Brett's side for the second time was that he was moving -- and with that movement came intense pain. Brett moaned loudly. The young bushfire brigade first-aid instructor, knelt beside Brett's head. With a wound dressing from the first-aid kit in her left hand, she applied direct pressure to the bleeding right temple. With her other hand, she used a "pistol-grip" on Brett's chin to lift his jaw and protect his airway. The possibility of spinal cord injury discouraged her from doing more.
The sound of sirens had become louder and as the loudest one came to a stop directly south of where they stood, the Bushfire Captain dispatched the other 2 bushfire fighters back along the trail, instructing one to report the situation at headquarters and the other to wait on the walking track above them to show other rescuers the way down the steep slope to where Brett lay.
On board the helicopter, the Rescue Crewman was in the co-pilot seat busily notifying police, ambulance, and fire brigade radio rooms of their updated ETA. 2KJ, the ambulance radio room, advised that there had been no confirmation of the patient's injuries at that stage and that the Hawkesbury Car would be on scene in 2 minutes. The helicopter was instructed to switch to Channel 5 and converse directly with that car. Fire Brigade radio advised that their first unit was at the car park and its officers were walking in. Police VKG informed the helicopter crew that PolAir and the Special Operations Group were available to fly in cliff rescue gear if needed. VKG also advised CareFlight that "Berowra-Two" was on scene and that Launch Brooklyn was en route and wished to converse direct with the helicopter on Marine Channel 67. The pilot requested that "Berowra-Two" investigate whether a landing site might be available in the vicinity.
In the back of the helicopter, the doctor and paramedic double-checked their harnesses and carabineers, knowing that the first responsibility of all emergency service personnel was not to become a casualty themselves. The doctor was a part-timer with CareFlight. His regular job was as Deputy Director of Intensive Care at a major Western Sydney Teaching Hospital. Nine years out of Medical School, he was an accredited specialist in Intensive Care and had been on the CareFlight Medical Roster for 18 months where he had learned winching, rappelling, and helicopter aircrew skills. Although he was accustomed to dealing with critically-injured patients in the hospital environment, he had also done more than a few jobs in the bush or at the road side as a CareFlight Medical Crewman.
The New South Wales Ambulance Paramedic aboard the helicopter was one of 5 seconded to CareFlight as a member of the elite S.C.A.T. -- Special Casualty Access Team. He was one of about 50 senior ambulance paramedics who had passed an exacting physical fitness test and then undergone extensive additional training in roping, rappelling, rock climbing, bush survival, scuba diving, and other assorted skills designed to enable the provision of advanced life support measures to victims located just about anywhere. Although their backgrounds differed before they joined the helicopter crew, the combined skills of the Intensive Care Doctor and the S.C.A.T. paramedic that were on board the CareFlight helicopter would provide a level of pre-hospital care unequalled virtually anywhere in the world. Whether it would be enough to save a young life that day remained to be seen.
At the base of the cliff where Brett lay, the sound of sirens and the approaching helicopter brought a feeling of immense relief to Gavan and the 2 Bushfire personnel. But for Brett, his return to consciousness brought almost unbearable pain. He tried to wipe the blood from his eyes but he could not lift his arms or move his hands. He became aware of a helicopter overhead and closed his eyes against the rotor wash. Although no one could know it at that time, Brett had already lost over a litre of blood. At least half a litre had pumped from his lacerated temple onto the sandstone before first aid was applied. Another 100 millilitres was lost due to fractured forearms and a dislocated wrist, and at least 400 millilitres was lost around his fractured left leg and dislocated ankle. If anyone had measured it at that moment, Brett's pulse rate would have been 130 and his blood pressure 95 over 50. The steadily growing mass of blood inside Brett's skull which the doctors would later refer to as an "extra dural haemorrhage" had not yet manifested itself. The most immediate life threatening process was what the doctors would call "hypovolaemic shock" -- a loss of body fluid. The depressed systolic blood pressure slowed -- but did not stop entirely -- the elevation of pressure within Brett's cranial cavity. The time bomb was still ticking . . .
By 2:46 pm, the last of the emergency units had arrived at the staging area. One of the general duties ambulanceman had gone down the walking track. The other, the Hawkesbury River Station Officer, remained at the car park staging area near the Berowra Punt. When the paramedics arrived from St. Ives he was ready to direct them along the walking track to where Brett lay. He then radioed to 2KJ to place Hornsby Hospital on alert for an incoming casualty. By the time the Fire Brigade Rescue Squad reached Brett with the heavily laden stretcher, the first ambulance officer had almost caught up with them.
While they unloaded the gear, the ambulance officer quickly assessed Brett and placed an Oxygen mask over his mouth and nose -- connecting it to the Oxy-Viva the firemen had brought in. He then radioed a message back to the Station Officer that the patient had been located and had multiple injuries including fractured leg, dislocated ankle and wrist, head injury, and query spinal injury. The ambulanceman, a "Level 4" officer trained in advanced life support, asked how long the paramedics and helicopter would be, and requested that a spine board and spinal lifting sheet be sent in. He then took over the application of direct pressure to Brett's right temple and started asking Brett questions to determine his level of consciousness and confusion.
The Station Officer secured the requested items from the back of the ambulance and gave them to 2 volunteer firefighters who had been sent to retrieve them. On board the helicopter, the medical crew had monitored the first report from the ambulance officer as they flew over the site. The pilot had spoken by radio to "Berowra-Two Portable" -- the young constable who had walked in with the fire brigade rescue squad -- who indicated that there was nowhere to land in the immediate vicinity, but that a small clearing downhill to the west and downstream to the north appeared level enough to allow a winch. It was only about 40 metres from where Brett lay.
The pilot hovered over the middle of Berowra Creek while the rescue crewman unstrapped and slipped into the back of the helicopter, securing himself in a "monkey harness" tethered to the floor, before opening the sliding door beneath the rescue winch. Once he was in position, the crewman read out the pre-winching checklist before directing the pilot into a 75-foot hover amongst the top of the gum trees.
The S.C.A.T. Paramedic had readied the medical pack in preparation for the winch down. He then removed the electrical cord connecting his flight helmet from the aircraft intercom system and plugged into a portable radio on his belt. He had previously made a check-call while they were en route to ensure the portable radio worked.
Having directed the pilot into position, the rescue crewman ran out about 2 ½ metres of winch cable slack, bringing the winch hook into the cabin and across to the Paramedic. Only after he and the medical pack were securely hooked on did the Paramedic undo his seat belt and fasten it behind him, moving across to the open door of the helicopter as the crewman winched in the slack cable. Seconds later the paramedic was on his way down through the branches of the gum trees to the slope below.
As he leant out the door with one hand on the winch control and other hand on the winch cable, the rescue crewman kept up a continual "patter" over the intercom -- keeping the pilot appraised of clearance from the trees, his position over the minuscule clearing, and the "down-the-wire-man's" progress toward terra firma. His was possibly the most diverse job on the helicopter, ranging from co-pilot/navigator to radio operator, mission co-ordinator, safety officer, winch operator, and medical assistant. During operations in close proximity to obstacles, he was the pilot's eyes below and behind the helicopter.
As the paramedic neared the ground, the rescue crewman eased off on the winch control, slowing his descent for a soft touchdown. Only after he was sure the paramedic was on firm footing did he winch out sufficient cable slack for the paramedic to disconnect from the hook. As the crewman retrieved the empty hook, the paramedic came on the air for a radio check. The pilot acknowledged and instructed him to check on the patient and the suitability of the Fire Brigade's basket stretcher for use with the helicopter. Within 40 seconds, the paramedic radioed confirmation of the suitability of the basket stretcher on scene and reported the patient as probably having a closed head injury and requiring the doctor to be winched in.
Securing the "pulse oximeter", C-size oxygen cylinder with regulator, "blood bucket" 4-point lifting harness, and "tag line" from the back of the helicopter, the CareFlight Doctor was in the same fashion winched to the ground 40 metres north west of where Brett lay, now surrounded by rescuers and ambulancemen. Once the empty cable was retrieved, the helicopter withdrew from the immediate vicinity, orbiting a kilometre downstream so that the noise and rotor wash did not hinder efforts on the ground. It was 2:52 pm. Thirty-Nine minutes after he fell, Brett had a Doctor, three Level 5 paramedics, and a Level 4 ambulanceman as well as nearly a dozen police, fire brigade, and volunteer bushfire brigade personnel at his side. The number of persons directly involved in the operation had risen to 36 with many more indirectly involved.
"Berowra-Two Portable" radioed a message to "Berowra-Two" to stop any further parties coming down the walking track as more than enough personnel were on scene and any more would over-crowd the area. "Berowra-Two" relayed the message to "VKG" and asked for a Sergeant to assist at the car park. "Berowra-One" acknowledged the call with an ETA of 6 minutes. By the time the CareFlight Doctor climbed the slope to where Brett lay, the 3 paramedics had already strapped a cuff around Brett's good arm and reported a blood pressure of 90 over 50 with a pulse of 130.
Questioning the Paramedics about their initial assessment, the doctor learned that Brett's level of consciousness was depressed and he was responding to pain only. He was told there was blood in Brett's mouth but that his airway not been obstructed. Brett's breathing was shallow and laboured but when the doctor listened to his chest through a stethoscope, air entry on both sides appeared to be equal. Chest injury, a major killer in blunt trauma cases, did not appear to be present in this patient. But the low blood pressure and rapid pulse -- what the doctors and paramedics called "hypotension" and "tachycardia" -- were a major concern.
Already one of the St. Ives paramedics had inserted an intra-venous cannula in Brett's uninjured left arm while the other one connected a plastic bottle containing haemaccel -- an artificial plasma solution -- to a rapid transfusion set which was then purged of air and attached to the cannula. The doctor asked the S.C.A.T. paramedic to remove Brett's right shoe and set up another IV line with whole blood from the blood bucket. The Level 4 ambulanceman sought and received the Doctor's concurrence to start bandaging and splinting Brett's right arm and left leg.
The spinal lifting sheet and spine board had arrived from the car park by that stage and the fire brigade personnel had laid out the basket stretcher, spine board, and lifting sheet on another flat rock a few metres away. A "belay" pulley was secured to a piece of webbing that had been tied around a 4-tonne boulder a few metres to the north of the one Brett lay across. Firemen were busy laying out ropes down the hill toward the winching site and running through the "belay" pulley to the basket stretcher.
Satisfied that the clinical skills of the Level 4 and 5 officers were being well utilised to treat the critically-injured patient, the Doctor stepped back to review the situation and plan ahead. His mind moved to the ABC's of emergency medicine: There was blood in Brett's mouth, confirmation that his Airway would have to be carefully monitored. His Breathing was improving but was still shallow and laboured. Circulation had been a problem but the worst haemorrhaging had been stopped by the first-aider and the bandaging and splinting coupled with the whole blood and haemaccel infusions were restoring Brett's blood pressure to what it should have been. Airway Obstruction and Hypovolaemic Shock -- two of the major reversible causes of death from trauma -- were being monitored and/or reversed. Invisible to those treating him, the "extra-dural haemorrhage" grew as Brett's blood pressure raised. The time bomb inside Brett's skull ticked faster . . . .
Learning that Gavan had been Brett's companion at the time of the fall, the Police Constable took details of both Brett's and Gavan's full names, addresses, and phone numbers, and recorded them in his notebook along with Gavan's description of the accident. As he did so the thought crossed his mind that he might one day be reading from those notes at a coronial inquest.
Brett had been semi-conscious, restless, and irritable when the first ambulanceman arrived, but he was able to say his name and knew what day of the week it was. But soon after he had become totally confused and did not respond to voice commands. He moved his arms and legs and responded to pain, as when his broken leg was placed in a plastic blow-up splint -- indicating that, if he did have a broken neck or back from the 9 metre fall, the spinal cord had not yet been damaged. It would be necessary to move him with the utmost care to ensure that the bundle of nerves running down the centre of the spine was not damaged by sharp bony fragments.
The Doctor asked for updated vital signs as he examined the laceration and bruise over Brett's right temple. Flashing a torch into Brett's eyes, he thought the right pupil looked slightly larger and less reactive than the left pupil. With the first unit of whole blood and half the bottle of haemaccel infused, Brett's blood pressure had risen to 100 over 60 and his pulse had dropped to 100. If he could have seen inside Brett's head at that moment, the doctor would have seen that about 35 millilitres of blood had leaked into the "extra-dural" space behind Brett's temple from the ruptured artery. The blood was putting pressure on Brett's brain, forcing it to the left side of the cranial cavity. The movement in Brett's brain put pressure upon and stretched the "oculo-motor" nerve between brain and right eye -- dilating the right pupil and disabling the involuntary mechanism that causes one's pupil to contract under bright light. There was also compression of the "lateral ventricle" which destabilised Brett's respiratory rate and blood pressure mechanisms.
Although he couldn't see the time bomb ticking inside Brett's head, the Doctor suspected what was happening. He began to suspect that the race to save Brett's life might be run more closely than he had initially thought -- and that it might be lost. He instructed the S.C.A.T. paramedic that Brett would have to be evacuated as soon as possible and taken to the closest major trauma centre where neurosurgery facilities would be available if required. He also decided that he was going to insert an endo-tracheal tube into Brett's throat which would allow positive ventilation and seal the trachea to prevent aspiration of blood or stomach contents into the lungs. He asked the St. Ives paramedics to prepare the necessary equipment while he placed a cervical collar around Brett's neck.
By this time Brett was deeply unconscious. The S.C.A.T. Paramedic had scouted the area and decided that there was no better spot for winching than the one they had used before. He radioed that fact to the helicopter and also advised him that they would be ready for a winch in about 10 minutes. He passed on the doctor's request to go to the closest trauma centre and asked which of Westmead or Royal North Shore Hospitals was closer. The pilot advised that Royal North Shore was marginally closer and had good helipad access to the hospital.
The rescue crewman called the RNS receiving room on the Cellphone and gave them early warning of the incoming patient. He also cautioned them that he would only be able to give about 7 minutes notice of their actual ETA once they were en route. RNS receiving room agreed to warn Hospital Security of the flight and to notify the Director of the Accident and Emergency Unit to be available.
Back on the ground, the S.C.A.T. paramedic explained to the Fire Brigade Rescue team that they would need to use the 4-point lifting harness and "tag line" from the helicopter because of regulations requiring such items to be specifically approved by the Civil Aviation Authority when attached to a helicopter. The doctor double-checked all the equipment laid out by the paramedics and positioned himself at the top of Brett's head. He had previously drawn up sedative and paralytic drugs which would relax Brett's muscles, depress his "gag reflex", and inhibit the rising intra-cranial pressure. Satisfied that everything was ready, he injected the drugs into the IV site.
Within seconds Brett's body shuddered and then relaxed. Using an instrument called a "laryngoscope", he lifted Brett's lower jaw and tongue so that he could visualise the vocal cords, deftly passing the plastic tube between them, curling it in front of the oesophagus, and into the trachea. As he did so, the "Level 4" ambulance officer applied "cricoid pressure" to the area of Brett's "Adam's Apple".
Once in position, he used a small syringe to inflate a cuff around the bottom of the tube with air to seal it into position. By the time the Doctor finished this, one paramedic had already taped the top of the tube and the other was in the process of connecting the endo-tracheal tube to a Resuscitation Bag which had which had been assembled and connected to the C-cylinder of Oxygen. From that point on, they would have to breath for Brett by squeezing the resuscitation bag. Lastly, the S.C.A.T. Paramedic connected the Pulse Oximeter and placed it beside Brett on the rock. From then on, a continual digital read-out of pulse rate, oxygen saturation, and blood carbon dioxide levels would be available to the medics. That done, Brett was gingerly lifted just high enough above the rock to facilitate placing the lifting sheet beneath him.
With the sheet in position, Brett could more easily be lifted off the rock to allow the spine board to be slid under him. Once he was on the spine board, the whole affair was placed into the basket stretcher with the Pulse Oximeter and "C"-Cylinder at the foot of the stretcher. Volunteer bushfire fighters took turns holding the "drips" at arm's length above their heads.
Two of the Firemen strapped Brett in while the other two organised the Bushfire Brigade personnel into a task force to pass the basket stretcher down the rock rubble to where it could be carried down the hill to the winch site. The belay rope passed through the pulley and attached to the stretcher would be used to control the descent. One fireman aided by the police constable and a bushfire brigade volunteer were positioned on the belay rope to help control the movement of the basket stretcher across the rubble and down the steep slope. At 3:05 pm, Brett was lifted off the rock upon which he had fallen and was being painstakingly lowered down the slope to the winching site.
Once clear of the rock rubble, it was possible for six people to carry the stretcher into position. The S.C.A.T. Paramedic then went ahead and started laying out the "tag line" -- a 5 millimetre nylon cord with a break-away link and a quick disconnect -- which would be used to stop the stretcher spinning as it was winched up through the swirling rotor wash of the 3 ½ tonne helicopter. The Doctor checked his harness and attached an extension link which would position him with the stretcher at chest height so that he could monitor and "bag" the patient during the winch.
As Brett was placed on the ground in the centre of the tiny clearing, the S.C.A.T. Paramedic attached the "tag line" and 4-point lifting harness to the basket stretcher. The Doctor asked a St. Ives Paramedic to "bag" while he quickly checked Brett's chest with a stethoscope. He asked the other paramedic to inflate a blood pressure cuff around the plastic blood bag which was then placed across Brett's chest in the stretcher.
The Level 4 officer radioed to his Station Officer that the patient would be winched on board and flown direct to North Shore Hospital. The S.C.A.T. paramedic radioed to the helicopter that they were ready for a winch pick-up from the site previously used. As the helicopter hovered into position, the doctor once again flashed a pen light into Brett's eyes. The right eye had improved but was not normal.
On board the helicopter, the word came through that the patient was ready to be lifted. The pilot and rescue crewman ran through the pre-winch checklist once again before the pilot nudged the cyclic stick forward toward the tree-covered slope.
Like most commercial helicopter pilots in Australia, the CareFlight pilot had gained his early commercial experience as a mustering pilot in the northern outback. Later he had gained valuable sling load and mountain flying experience in the New Guinea highlands before joining CareFlight as one of 3 full-time Captains. And although the 3.5 tonne, Twin-690 horsepower turbine-powered Dauphin was bigger and more sophisticated than anything he had flown previously; and although his repertoire of flying skills had since expanded to include instrument flying and over-water search and rescue -- it still seemed to him as he manoeuvred for the extraction that he had spent half his flying life hovering around trees with bits and pieces dangling beneath his helicopter.
As they crossed the creek line and the winching site came into view, the rescue crewman could see nearly a dozen rescuers clustered around the stretcher. He quickly radioed the S.C.A.T. Paramedic to remove all unnecessary personnel from beneath the helicopter. The S.C.A.T. Paramedic knew of the potential danger of standing beneath the helicopter with whirling rotor blades only metres from towering gum trees. He also knew that, having thrown themselves so thoroughly into the efforts to save Brett's life, the rescuers found it difficult to turn their backs and walk away. He motioned for the Police Constable to help him clear the area.
Allowing the winch hook to touch the ground and discharge any static electricity, the doctor snapped the metal ring from the 4-point lifting harness into the hook first, then hooked onto the extension link which he had connected to his harness before extending his arm horizontally, and giving the "thumbs up". Ten metres uphill, the S.C.A.T. Paramedic placed tension on the "tag line" to ensure the stretcher didn't start to spin as it cleared the ground.
On board the helicopter, the rescue crewman winched in cable to take the slack out and then directed the pilot "up gently ten feet" -- thus allowing the pilot to feel the centre-of-gravity shift for himself and place the load back on the ground if it was too great and control limits were reached. But the load was within limits and as soon as the pilot indicated it was okay the rescue crewman started to winch in. Even as he hung from the winch hook, the doctor continued to "bag" the patient As the load came level with the floor of the helicopter, the rescue crewman released the tag line and rotated Brett's head inboard.
Directing the pilot to take control of the winch and winch out, the crewman guided the basket stretcher across the floor of the helicopter against the rear cabin bulkhead. The doctor crawled across the floor beside the stretcher and once well inside the cabin, connected himself to a second "monkey harness" before releasing himself from the winch hook. Continuing to bag, he again checked the patient's vital signs.
Because of the helicopter's noise, he could not use a stethoscope, but was able to measure systolic pressure by feel and pulse rate by the Pulse Oximeter. Brett's vitals were BP 100, pulse 80. As soon as he saw the "tag line" snaking back down through the trees, the S.C.A.T. Paramedic grabbed the medical pack and blood bucket, and started coiling the "tag line" back inside its pouch. By the time the empty winch hook reached the ground, he was ready to connect to it and be winched out. A minute and 15 seconds later, he was strapping into a seat in the back of the helicopter and the pilot was nosing over to gain speed before climbing to 1000 feet in the direction of Hornsby.
It was 3:12 pm. Fifty-nine minutes after he fell, Brett McLeod was en route to the Royal North Shore Hospital.
It had taken just over 7 minutes to cover the 28 kilometres from Westmead to Berowra. Because the basket stretcher prevented the sliding door from closing fully, airspeed would be restricted to 100 knots and the 27 kilometre flight to Royal North Shore Hospital in St. Leonards would take just under 9 minutes.
The rescue crewman had a good deal to do in that short time. He first dialled the RNS switchboard, gave the ETA of 3:22 pm, asked for Hospital Security to clear the helipad, and then asked to be put through to the Director of Accident and Emergency. When the A&E Registrar answered, the crewman asked him to stand-by for a call from the CareFlight Doctor before signalling the to the CareFlight doctor that his call was through. Throughout the massive hospital complex, pagers "bipped", telephone extensions rang, and P.A. speakers summoned the affected personnel into their respective work areas to deal with the incoming emergency case.
On board the helicopter, the pilot had selected the Sydney Clearance Delivery frequency and called: "Helicopter CareFlight One, Medical One Priority, estimating overhead Hornsby at time one-four for Royal North Shore Hospital at one thousand -- request airways clearance." After a few seconds the reply came back, "CareFlight One, cleared as requested, maintain one thousand, squawk normal code and call approach one-two-four-decimal-four at Hornsby. Switching frequencies, the pilot overheard the approach controller directing the Channel 9 helicopter which had just departed from Willoughby on its way to cover the rescue to "turn right; climb to one thousand, five hundred and report cruising due inbound medical priority traffic."
On the Cellphone, the CareFlight Doctor had spelled out the situation to the A&E Registrar who had taken the call. The message was succinct:- "Male approximately fifteen old, previously healthy, multiple trauma due fall of approximately 10 metres, compound fracture left tibia and fibula, query compound fractured right radius and ulna, chest clear, query spinal injury -- nil deficit, query closed head injury, right pupil fixed and dilated, pulse 60, BP 120 systolic, patient intubated and ventilated on 100% oxygen at eleven litres at twenty per." To a layman overhearing the call, the clinical language would have belied the life and death struggle going on in the back of the helicopter at that moment as it crossed a thousand feet above the leafy streets of West Pymble. But the full impact of the situation was not lost upon the A&E Registrar. He hung up the phone, then picked it up immediately and placed the CT-Scanner on notice for an urgent head scan. Next he paged the neuro-surgical and orthopaedic consultants and the diagnostic radiology registrar and asked them all to attend. He then headed for the helipad.
As he walked through the sliding glass doors into the late afternoon sunlight, he could hear the helicopter on approach to the pad. At that point, including all the radio and telephone operators, air traffic controllers, technicians, police, ambulance, and fire brigade personnel, over 60 people had become involved in the fight to save Brett McLeod's life.
In the back of the helicopter, the paramedic connected Brett to a cardiac monitor and then took over ventilation while the doctor flashed the pen light torch once again into Brett's eyes. The right pupil was now fully dilated and remained so with the light shining directly into it. The left pupil was larger and less reactive than when he had checked it only a few minutes before. Time was running out for Brett.
The rescue crewman read out the pre-landing checklist and the doctor and paramedic tightened their safety harnesses for landing. The reception team at the RNS helipad had grown to include neuro-surgical and orthopaedic registrars.
As the helicopter touched down, the rescue crewman radioed 2KJ with the arrival time and then exited the helicopter to brief the reception team. After switching off the radios and electricals, the pilot moved the fuel control levers to cut-off and as soon as the rotor RPM dropped below 170, he applied maximum rotor braking to bring it to a stop.
By the time he got unstrapped, the basket stretcher was already off-loaded and placed onto a trolley. As the wards men pushed it briskly along the footpath toward the main hospital block, the CareFlight Doctor continued to squeeze the resuscitator bag while he retraced the accident, symptoms, treatment, and provisional diagnoses to the receiving medicos.
As the CareFlight Doctor spoke, the S.C.A.T. Paramedic retrieved a small glass tube containing Brett's blood from his flight suit. A nurse was despatched to pathology with the blood. Within four minutes, it would be "typed" and "cross-matching" begun.
On the basis of the information received, the A&E Registrar directed that Brett be taken straight to the CT-Scanner instead of the Receiving Room as would have normally been the case. It was 3:23 pm when Brett's trolley was wheeled through the doors of the Royal North Shore Hospital.
At 3:24 pm Police Car "Berowra-One" pulled up outside an address in Hornsby Heights. Hearing the car pull up, Brett's mother peered out the window. When she saw Brett's mate Gavan and a Police Sergeant getting out of the car, she was out the front door and down the front path to meet them before they could even open the front gate.
Hearing her scream, Brett's father emerged from beneath the bonnet of the family sedan in the carport alongside the house. As calmly he could, the Police Sergeant explained what had happened and what was being done. He offered to drive them to North Shore Hospital -- knowing they should not drive themselves in their distressed state. The Sergeant reassured them that everything possible was being done for Brett.
Still on the spine board and lifting sheet, Brett had been placed within the drum-shaped cavity of the CT-Scanner. Similar but far more sophisticated than an X-Ray, the CT-Scanner used a computer to generate a series of cross-sectional images at pre-set intervals. Because of the time imperative, the radiologist directed the operator to set the machine for one-centimetre "cuts" instead of the usual 5 millimetres.
The Neuro-Surgical Registrar settled into the second seat at the console behind the operator, studying each cross-section as it appeared on the screen in turn. At the 4 centimetre "cut", the lesion behind Brett's right temple started to show. At 8 centimetres, the centre line of the brain was deflected nearly a centimetre to the left. From 10 centimetres down, the head scan was clear. Scanning the neck and back would have to wait until later. There was no more time to waste.
As the wards men pushed the trolley toward emergency theatres, the surgical and anaesthetic registrars were already scrubbing and a theatre sister was placing sterile instruments on a tray. Inside theatre, a nurse hurriedly shaved Brett's head and painted a brown-coloured disinfectant all around his right temple. As the bag was removed and Brett's endo-tracheal tube connected to the anaesthetic respirator, the Anaesthetist measured his BP at 140 over 100. The Pulse Oximeter which still rested on the stretcher beside Brett showed his heart rate had dropped to below 50. Brett was dying before their eyes.
It is a phenomenon which pathologists call "coning" -- an innocuous sounding name but one which is rapidly fatal and once beyond a certain point, entirely irreversible. As a medical term, it is most frequently found in post-mortem reports.
"Coning" occurs when elevated intra-cranial pressures force the stem of the brain (the part anatomists call the "medula oblongata") down into the bony orifice (called the "foramen magnum") located at the base of the skull and the top of the highest cervical vertebra.
That part of the brain coordinates all the body functions and when it is damaged it is a condition incompatible with life, as the doctors so quaintly express such things.
As the neuro-surgeon incised across Brett's temple and retracted the tissue to expose the outside of his skull, "coning" was imminent. Placing the surgical drill bit against the exposed skull, he began to drill. As he penetrated the bony structure, a thin bright red stream of arterial blood spurted across the room, staining the surgeon's green gown and the grey tile floor of the theatre.
He then made another incision and drilled another "burr-hole" one centimetre above and forward of the first. This time, blood only spurted a few centimetres. The anaesthetist noted that Brett's heart rate was climbing and the blood pressure starting to drop. Inside Brett's skull, the brain was returning to its normal position. It was 3:37 pm. The bomb had been de-fused.
The battle to save Brett McLeod's life which had begun at 2:14 pm that date and which had up to that time directly involved at least 66 people was not yet over. But its eventual outcome was far more predictable. Ahead of Brett lay more neuro-surgery, hours of orthopaedic surgery so that he might be able to walk and run again, days of intensive care, and further weeks of hospitalisation. There would be months of physiotherapy and a period of mental adjustment to his temporary incapacity. But when Brett McLeod's distraught parents arrived at the Royal North Shore Hospital in Police Car "Berowra-One" at 3:51 pm, they were told that a crisis had passed and that prognosis for Brett's recovery without serious disability was good. They would not be told, nor would they ever know, how close they came to losing Brett on that sunny, winter afternoon.
The following day, a small headline on page 5 of the "Daily Telegraph-Mirror" read: "Helicopter Plucks Cliff Fall Boy to Safety". In the few short lines that followed, the story explained that the youth had fallen onto an inaccessible bush location sustaining serious injuries and that a rescue helicopter had winched him out and flown him to North Shore Hospitals where doctors had operated to save his life.
There was no mention in the story of the fire brigade, ambulance, and police officers -- nor of the volunteer bushfire brigade members -- who had hiked into the location to treat and rescue the youth. Nothing was reported about the first-aider who had applied direct pressure to stem the torrential haemorrhaging that could have easily taken Brett's life before the doctors or paramedics even arrived.
There was no kudos for -- nor even a mention of -- the skill and dedication of radio controllers and supervisors who -- on the sketchy and unconfirmed information available to them -- made decisions to respond the facilities and equipment which eventually made the operation a success.
No credit was given to those who resisted the urge to rush to Brett's side in order that proper communications and co-ordination links be maintained with the staging area. Nor did the switchboard operators, behind-the-scenes technicians or even the air traffic controllers rate so much as a mention or a second thought to those who heard or read about the rescue operation.