A Final Arc of Sky: A  Memoir of Critical Care by Jennifer Culkin (Beacon Press, $24.95, 9780807072851/0807072850, April 2009)

Jennifer Culkin began her nursing career in the NICU and PICU (neonatal and pediatric intensive care units) more than 30 years ago, so she is intimately acquainted with heartbreak and death. That alone would be interesting, but she is also a marvelous writer, mixing tragedy and reflection with luminous prose. One of her first patients was a tiny girl with "an immense head, a wasted body, and the skin of a fish . . . a sacrifice for a primitive god, pinned on her slab by the sheer mass of her head. Entranced and alone behind the translucent leavings of her skin, a halo made of insect wings." When Culkin held her, "she settled in, turned toward my warmth with hers. Her own heat was so slight, like her hold on earth."
 
After moving to the Pacific Northwest, Culkin became an emergency flight nurse and writes compellingly of the drama inherent in this work. Describing a thrash, or a difficult flight, she says the common denominator of all thrashes is that a patient is trying to die while in the air. She describes the confinement of the helicopter interior: the patient's legs extend down into the cockpit where a copilot would sit; the nurses are wedged on either side of the patient, but out of their seatbelts, rolling around with their instruments as they struggle to keep the patient alive; bodily fluids often splash around. "After a thrash, the cabin resembled the site of a depraved murder."
 
She masterfully laces sky and flight into this narrative of medicine and trauma. Once, as they were about to take off, she wanted "to tell the dad I'd love his boy as much as I could. But it was already too late. The next hours would be bereft of tenderness, a matter of the process running its course." Trauma flights from the field with CPR in progress end in death most of the time: "If you could scoop a victim out of the wreck and put him directly in the OR with a trauma team standing by, you might sometimes get a save. But not with time and distance working against you, not with miles of sky, an invisible gusher somewhere deep in the interior firmament, and cells winking out by the millions in every body system." And patients are not the only deaths she encounters; she writes movingly of the deaths of colleagues, when flights are overdue and the only question is not if there are friends on it, but which ones.
 
A few years ago Culkin was diagnosed with MS and had to go on disability, but she is still tied to her calling. "Several times a week the sound of the [Agusta helicopter] overhead hooked me from sleep, deep in the night. It nailed me coming and going, outbound and inbound on flights to the peninsula . . . For every flashing light up there, there's a different LZ, another story, another undignified human tumble. The sky, hardboiled and helicoptered, will never let me go, not completely."
 
Decades after Cullkin moved from ICUs to the back of a helicopter, she thinks of a pilot who would say, at lift-off, "Four souls aboard," and muses on how fragile we are. That sense of fragility as well as resiliency and strength follow Culkin through her life as she marries, has children and cares for dying parents. We are privileged to share her passion and heartbreak as we in turn follow Culkin through the skies and the lives she limns so eloquently.--Marilyn Dahl
 
Shelf Talker: An eloquent and compelling memoir by a critical care and flight nurse that soars with tragedy and tenderness.