Decisions

Have you thought about the repercussion of a decision you have made and the cascade of events that may result from that decision? I've spent a lot of time over the past week pondering this concept as a result of a code one flight I made over the weekend.  

This past weekend was my first "on call." The on call pilot is required to stay near home and be ready to drop everything and go to the airport should a code one be called in. A code one is our term for an emergency medical evacuation flight. If the patient is not immediately given medical care, life is endangered. These flights are very rewarding since they often are life-saving, but also leave us little margin for error and require concentration and good execution by the pilot. Balance is key. As pilots, we are responsible to put safety first, and rushing is always a danger to safety. On the other hand, on a code one, we do all that we can to execute our piloting duties speedily to minimize the time from when we receive the call to the time when we help load the patient onto an ambulance. 

MAF airplanes ready for departure

Last weekend was a holiday weekend in Lesotho. Friday was Independence Day, so I was on call Friday, Saturday and Sunday. Friday had no calls, but I went into the hangar and performed a preflight inspection on the plane so it would be ready to dispatch in case there was a code one. On Saturday morning, my phone rang before 7 am. A premature baby was in trouble and needed and evacuation from a mountain health clinic to a district hospital. The flight went very well and I was home in a few hours. That afternoon, I had another call. This time, a man had a gunshot wound to the neck and needed to go from one of the district hospitals to the main hospital in Maseru. Again, the flight was uneventful and the outcome was successful. By 4 pm, I had reached "cuttoff time," the time when there is not enough time to complete a flight and return before sunset. We cannot fly at night because there is only one runway here in Lesotho with functioning lights, and because we are not allowed by regulation to fly at night if we have not done so recently. To fly at night would be both illegal and dangerous.

Sunday dawned clear and calm. All morning I waited for a call. Our usual church was too far away for me to dispatch quickly, so we attended a different church closer to the airport. By 2 pm I was beginning to relax - there probably would be no calls today. This was great because I had planned to have a meeting with a young Basotho lady whom I'm mentoring toward an aviation career that afternoon. Ausi Tebello would be arriving at our house around 3. Then it happened; at 3:07, my phone rang. There was a code one from one of our furthest airstrips, the site of a district hospital about 85 nautical miles away. I was told it was a premature baby. Using a spreadsheet developed by one of our pilots that factors in drive time to the airport, preparation time, flight time, loading time, etc., I determined that I had about 1/2 hour of extra time to complete the flight before sunset at 6:12 pm. The forecasted winds were manageable and though there were scattered cumulous clouds, they are common in the afternoon and nothing to worry about. It was a go! As I drove out my driveway, I met Ausi Tebello arriving. I asked her if she wanted to come along on the code 1. She was elated at the opportunity to go and experience aviation. Our meeting could happen another day. 

Someone loves flying!

By 4 pm we were airborne. I texted my flight follower that I was estimating arriving at the airstrip at the district hospital at 4:37. Our flight follower is a crucial component of the safety system at MAF. He or she sits in the radio room monitoring our progress via a GPS tracking system that is installed in each airplane. The flight follower performs a variety of tasks that reduce the workload of the pilot. For example, if we need a weather check, he or she will call our contacts at various airfields to find out winds and cloud conditions. The flight follower also communicates with the medical personnel bringing the patient to coordinate arrival times, etc. Most importantly, though, the flight follower is ready to notify key personnel and initiate search and rescue for us should we should have an inflight emergency. It is always a comfort to know we are being watched and cared for (by a human also) as we fly over the rugged mountains of Lesotho.  

Upon landing, I taxiied the airplane to the parking area where the patient was waiting. I saw a young person on a stretcher. As I prepared to transfer the person, whom I assumed to be a young mother, to the stretcher, I asked the age and was told "14." Then I asked where the baby was. After a moment of confusion, I was told that there was no baby. The young person on the stretcher was a young boy and there was never a premature baby. Such miscommunications are common. There was no problem, though, since I had brought the airplane stretcher. The airplane stretcher is a collapsible aluminum frame that allows us to strap the patient down and fasten the stretcher frame to the airplane floor so that the patient will not be bounced around if we hit turbulence. The boy was weak, intubated and semi-conscious. The attending medical personnel said they did not know what is wrong with him. I asked if he had TB and they said he did not (we wear masks for our protection if a passenger has TB). I loaded the boy on the stretcher and seated the attending nurse as well as the boy's grandmother.  A quick check of the weight and balance of the airplane confirmed that we were within limits.

Airplane Stretcher

Before departing I check my phone for messages. The flight follower has sent me several disturbing photos of a large gathering storm cell (thunderstorm) over the airport and explained "It's gusty and turbulent here" and "the wind sock is also full" (which means wind is at least 15 kts). The weather at base had deteriorated rapidly after my departure. It is time for a decision. I tell my flight follower that I am going to try. Perhaps the storm will dissipate or move away before I arrive. A lot can happen on a 45 minute flight, since most thunderstorms only exist for an hour or so. Besides, I have only about 1 hour and 15 minutes to suset. It is time to move. A few minutes after takeoff, our Chief Pilot, Bryan texts me with "are you flying? There's a big thundershower over Maseru now." He tells me there is lightning too. I peer into the distance trying to make out the storm that is more than 50 miles ahead. But the setting sun is in my eyes and I can't see much through the haze. Now my team is going into full support mode; Bryan and another pilot discuss options, check radar and tell me they think I can get through between rain cells. I'm flying the airplane and texting via WhatsApp with Bryan. Suggestions on where to go if I can't get through? We decide that option one is to go back to the district hospital because the patient will get best care there. In the back of my mind I know that conditions were going downhill there too, so I note the airstrips I pass along the route. Semenanyane and Katse Dam, both have airstrips that I can land on. The window of daylight is closing and I need to open as many options as I can. If I can't get through to base at Maseru, I have only a few minutes to spare for the return. I am going to the edge of our safety margins. 

Things look OK ahead - for now

My primary goal is to stay within those margins. Meanwhile I forge ahead. Now I see the storm. The sun is lower now and disappears behind the huge storm.  At least I can see what I'm heading into. The light is erie. It's 5:35 pm. Thirty-seven minutes to sunset. I am only 25 miles out and I receive a message from Bryan that there is light rain in Maseru but that the main storm seems to have passed to the north. I see a path through below the storm to one of our main landmarks that's only a few miles from our base! I point the airplane at the light that is past the darkness of the storm. At the same time I note a very clear area to my right and set the heading bug on the airplane to that area in case I need to turn away from the storm. I don't want to have a moment of confusion if I need to turn back. It's smooth sailing and we begin to descend about 20 miles from the airport. " We're going to make it," I say to Tebello who is seated next to me. Seconds later we encounter serious turbulence. The airplane is being tossed like a leaf. At almost the same time I see a lighting strike dead ahead, and within a few seconds left and right of where I'm pointed. There's no way forward that is safe. I bank the airplane hard toward the heading I had chosen and begin to climb, back toward the mountains I had just left. It is 5:43 pm. I have 29 minutes to get the airplane on the ground before sunset. 

The storm that made us turn around

I set the GPS for return to the airport at the district hospital and get on course. Having escaped the storm area, the turbulence is gone. I text Bryan and my flight follower to let them know I have turned back. The GPS estimates my arrival to be 6:08. I have four minutes to spare! As long as the weather is good at the district hospital airport. Has the door closed there too? I can always land at Katse or Semenenyane, but these are not ideal for the patient. Bryan texts me to assure me I'm doing a good job and remind me that the priority is to get on the ground. I begin my descent toward the district hospital. We pass through some light rain but the airport is clearly visible in the distance. I text the flight follower to call for the ambulance to pick up our patient. As I enter the airport pattern and prepare for landing, I see lightning strike a few miles away. After landing I send my "on the ground call" to my flight follower at 6:11 pm. My team and I breathe a sigh of relief and say prayers of thanksgiving. 

The patient is loaded into the ambulance and I tie the airplane down. With this stormy weather I have to be sure it won't be damaged. I check the fuel and find that there is just enough to return to Maseru in the morning and allow our required reserve fuel. My team has already started planning for how to get us back. The nurse, the patient, his grandmother, Tebello and I all ride in the ambulance to the hospital. I apologize to the grandmother and the nurse that I could not get through. We make a plan with the ambulance driver to try again at first light, 5:45 am. I text Karen to update her and find out that she has been following along on the computer, which allowed her to see all the messages going to and from my phone. The kids want to hear a voice message from me to know I'm ok. Karen tells me that all the wives on the MAF staff have reached out to her to make sure she's ok. I love our team! I send Bryan and the others a text thanking them for their help.

The nurse calls for a bed and breakfast for us and the ambulance takes us there. I am glad that my flight bag includes a few overnight items. Tebello has had quite an adventure and as we eat dinner we talk about the experience. I ask if she still wants to be a pilot after this. She is energized and excited. She tells me the only time she was afraid was when I made the turn back in turbulence. We discuss the crew resource management and safety factors that played into the decisions that were made. These are valuable lessons that I wish I had known better in my early piloting. After dinner, I am pretty tired and get to bed early. I have a early start to make in the morning.  

A nice comfortable room

It's 4:45 am on Monday. I have arranged to pay the owner of the bed and breakfast at 5:15 and the ambulance is coming to pick us up at 5:20. We ride the ambulance to the airport, and I jump off there to go get the airplane ready. The gate is locked, so we need to figure that out. Meanwhile, I vault over the gate, do my preflight checks and prepare the stretcher. The ambulance returns from the hospital and waits at the gate. I decide to try to save time by putting the patient on the stretcher in the back of the ambulance. He looks weaker this morning but he has enough strength to push my hand away and mutter protest as I strap him to the stretcher. No one can seem to find the person with the key to the gate. Time is ticking. I get the airplane toolkit and remove the lock. The ambulance drives up to the airplane while I trot back with the toolkit. 

Ready to go at dawn

As I open the door of the airplane and return to the ambulance for the stretcher, the nurse tells me the patient's heart has stopped! I know that he was well enough to push me away when I put him on the stretcher scarcely five minutes before. Incredulous, I ask if they had tried CPR. No, they say, we don't have a CPR mask. I shout, "we have one in the plane, start chest compressions NOW," and sprint to the plane. It's not there. I run back and start chest compressions. The nurse and I trade off with chest compressions while I rack my brain for a solution to the respiration. I remember my CPR training and we get the patient on the ground outside the ambulance for more effective compressions. The ambulance driver opens a compartment on the ambulance and starts looking in it. I find a respirator bag and toss it to the nurse. We continue CPR together for several minutes. I ask if there is an AED on the ambulance but there is not. I suggest we take the patient back to the hospital where they will have an AED. I ask Tebello to stay with the airplane since I haven't had time to secure it. On the drive we continue CPR, but there are no results. I hope that we are keeping his brain oxygenated until we arrive for the AED at the hospital. 

We put the patient on a gurney and wheel him to the OR. It's locked and takes a few minutes to find a key. I'm the only one doing CPR now as no one really has any hope. But I think, "what if this was my kid?" and continue. I help the nurses put him on the table and I ask "where's the AED?" "We don't have one." They put a monitor on the boy and pronounce him dead. I'm so angry. Angry that this hospital is so poorly equipped and at the apathy surrounding the situation. Sweaty and tired from the CPR, I walk out of the hospital in stunned silence. At the ambulance is the boy's grandmother. I tell her in Sesotho as best I can that we tried and that I'm sorry. What can I say? I have no words. It is a somber ride back to the airport. 

Back at the airport - reflecting on a difficult morning

Now I begin to second guess myself and my decisions. What if I had tried a little more to push through the night before? What if I had not stressed the patient with a flight the night before? What if I had tried to wait out the storm over Maseru in hopes of landing there before dark, instead of turning back? The decisions I made had been part of this boy's life ending. I have been reflecting on these questions for a while. I have concluded that that I did everything right. I tried my best. I did succeed in my mission to fly safely. I know that 4 people and me dead because I decided to fly and land after dark or fly into a thunderstorm would be even worse than the outcome than we had. Much worse. I am at peace with that. I am glad that in the week following this incident, the MAF team and I have flown more than a dozen missions that supported the health of people in Lesotho (including numerous code 1s), missions that would not have happened if I had made a decision Sunday night that led to an accident. Next time, given the same situation, I would do the same. I would have to.  

I have also been reflecting on deeper questions. Why would God allow a boy like this to die when he has hardly yet lived? What about his salvation? I don't have answers to these and I may not ever have them. But I do have faith. Faith is not for when its easy. It's for when it's not easy. 

Please pray for the people of Lesotho. Pray that the love of Jesus would fill the hearts of leaders and of their people so that they would live by the two great commandments to love God with all your heart and to love others as yourself. When this happens, people's lives are transformed, and when people are transformed, a nation is transformed. It can happen. Pray that God moves in this nation. 

Pray for the Mountain Kingdom