There’s a physiological response when a nurse in Renown’s Neonatal Intensive Care Unit (NICU) transportation team receives a call about a critically ill newborn who needs a higher level of care than the birth hospital provides.

It’s similar to a fight-or-flight response. 

The heart rate spikes.

Breathing quickens.

The world narrows to the immediate present. 

The nurse helps load up a roughly 30-pound, rolling “ICU-in-a-bag” and another 35-pound rolling bag containing respiratory equipment into an ambulance. The nurse works with a team of one or two other medical professionals depending on the situation, and the group aims to leave the Reno hospital within a half hour of the call. 

The staff then rides in the ambulance to stabilize and load up the baby and bring the child back to Renown’s NICU.

“Your mind is constantly thinking, ‘OK, with my supplies and my bag, how can I prepare to take care of this baby when I get there?’” said Brandi Coleman, a nurse on the transport team. “It's just like 100 miles an hour within a second.”

Another nurse on the transport team, Jennifer Johnson, said that getting to the baby as soon as possible is essential.

“Time equals tissue death,” she said. “So as long as they're not being provided adequate oxygenation, their brain status and their brain function is just going to start going downhill to where that can’t be recovered.”

Johnson and Coleman are two members of Renown’s NICU transport team — a small group of respiratory therapists, registered nurses and nurse practitioners.

The nonprofit hospital system offers Northern Nevada’s only Level III NICU, which can provide comprehensive care for newborns born prematurely or requiring special treatment for conditions such as underdeveloped lungs. 

The only other NICU in the area is at Reno’s Northern Nevada Sierra Medical Center, which has 12 beds and is certified as a Level II NICU, which means it can provide intensive care for sick and premature infants but is not equipped to care for more seriously ill newborns. Renown partners with the Regional Emergency Medical Services Authority (REMSA Health) to transport babies from hospitals within Reno, nearby Carson City and parts of rural Nevada and Northern California, including Winnemucca and Bishop, California.

A few years ago, when Kallie Johnson and her husband, Sterling, were living in Paradise Valley, Kallie Johnson had a complication in her pregnancy that required her to be flown to Renown, where she gave birth to a premature daughter. She had had a similar complication about five years earlier that doctors were unable to handle, leading to a stillbirth. 

She said she is thankful she had options that allowed her premature baby to finish growing and developing. She added that the constant care of the nurses and doctors saved her child’s life, and they became like family during one of the scariest and most stressful experiences she’s ever had.

“From my OB to the neonatologist to the nurses to the respiratory therapist, nobody ever shut a door in my face,” she said. “They value that you're there and that you obviously love your kiddo and their goal, and they tell you a lot, ‘We want your baby to grow and be healthy and go home with you.’”

Though Renown used to partner with St. Mary’s Regional Medical Center to provide staffing for transportation services, the partnership ended after St. Mary’s announced the closure of its Maternal Child Health Program in November 2022. Following the closure, Renown has taken on the full workload it used to split with St. Mary’s and now transports every baby requiring a hospital transfer in the region.

St. Mary’s decision to reduce the hospital's services didn’t affect REMSA’s capacity or ability to transport patients. In 2022 and 2023, data provided by REMSA shows the team averaged anywhere from 7 to more than 60 miles of travel in a given month and traversed more than 4,230 miles across the region. 

The NICU transport is one-of-a-kind and can be expensive. REMSA’s base rate for such an ambulance transport is $5,250, with an additional $30 per mile driven — costs that may be covered by insurance. A flat fee from the charges pays the transport team. 

Over the last two years, team members transported 192 babies, 100 of whom were transported solely by Renown personnel after St. Mary’s stopped providing maternal services.

Renown’s CEO and President Brian Erling said that the hospital had about two weeks' notice ahead of the closure and ramped up services, increasing staffing and eventually increasing the capacity of the NICU.

“We immediately did everything we needed to do,” Erling said in a recent interview. “It's expensive when you don't have notice like that, but we’ve got to take care of the moms; we’ve got to take care of the babies.”

Increasing capacity

When the NICU transport team leaves Renown to pick up a newborn from a hospital that doesn’t have the resources or capacity to meet the baby’s needs, members of the group squeeze together in an ambulance with a clear plastic enclosed crib referred to as an isolette between them. The isolette helps keep the baby warm and isolates the child from germs.

In a critical situation, there’s a nurse, respiratory therapist and nurse practitioner. Each has a specific role: The nurse practitioner is the team leader, the nurse helps stabilize the baby and the respiratory therapist ensures the baby can breathe. It’s just a nurse and respiratory therapist in situations with less urgency.

After the baby is safely in Renown’s NICU, the staff checks their bags, replaces supplies and ensures they’re ready for the next call. In a busy, 48-hour, on-call shift, the team might be called to as many as three transports. Data from Renown indicates the team conducts, on average, eight transports a month, with higher-traffic months such as July and November seeing anywhere from 11 to 19 transports.

“My heart rate doesn’t drop until the baby is in our unit because anything could happen,” said Casey Schafer, a nurse on the transport team.

Working as a member of the NICU transportation team is similar to what happens at Renown’s NICU floor but with additional challenges. There’s less assistance, and each group member has to be self-sufficient, make quick decisions and work cohesively as a team. It’s intensive, demanding work, where one decision can have life-threatening consequences.

As the only NICU transport team in the region, Renown is looking to grow the team, but it’s challenging.

A report from the Nevada Hospital Association described Nevada’s nursing workforce as facing “a crisis.” The report estimated that to address the crisis, the state would need an increase of at least 3,100 registered nurses, 3,200 licensed practical nurses and 5,000 nursing assistants to meet the national average. Without enough nurses, the report said health care costs would likely increase, and settings such as nursing homes may have to turn away potential patients.

To serve on the team, members must have NICU experience and receive specialty training to stabilize, resuscitate and transport newborn babies. The need for specialized training is often a limiting factor when recruiting for the NICU transportation team.

The work of transporting sick patients can also be dangerous. In February 2023, a REMSA Care Flight that was transporting an adult patient crashed, killing all five occupants. Though it's rare for babies to be transported by air (four air transports took place in the last two years, representing less than 1 percent of NICU transports by Renown and REMSA), staff on the transport team are aware of flight and travel risks.

Adam Heinz, chief operating officer for REMSA Health, said that REMSA worked with its aviation vendor to gain access to a fixed-wing plane to replace the aircraft destroyed in the crash. A fixed-wing plane has more room for specialized equipment and personnel and can fly further than a helicopter before needing to be refueled.

The organization announced it had replaced the fixed-wing aircraft Dec. 29, noting that fixed-wing flights would return to service Dec. 31.

Heinz, who has served with REMSA for 21 years, said REMSA has access to four helicopters “strategically stationed throughout the state,” and that the organization has partnerships to allow for other forms of air travel as well.

But even with access to aircraft, 99 percent of cases where a newborn is transported happen over the ground via ambulance, and doctors decide how to move babies and when to do so.

“Without having access to those services, there definitely would be different outcomes, and there would be a disparity to the access to that comprehensive care which we have here,” he said. “This partnership allows for us to be able to bring those services and bring safe access because it's not always appropriate or safe for the patient to use air services.”

Avoiding ‘an absolute nightmare’

Abe Chaparro, a supervisor of respiratory care at Renown, said if a baby needs oxygen or ventilation, he or another respiratory therapist will initiate and manage the devices to ensure the baby can breathe.

Chaparro spent six years working as a respiratory therapist at Renown before leaving to take a position as a manager at Banner Churchill Community Hospital in Fallon. He said he wanted a change of scenery and to try something different.

After two and a half years at Banner, he realized his passion was working with newborns and children and returned to Renown as the night shift supervisor for the Children’s Hospital. Though he had previously worked on the NICU transport team, he said he needs to recertify and train to return to the team, which he is doing.

Chaparro said it’s hard to explain why he returned to his job at the children’s hospital to somebody who doesn’t have kids, but it’s vital to understand that “the day that you become a parent is the single most joyful day of your life.”

“And so you get to be there for that occasion for people over and over again. And then your job is to make sure that that single greatest day of their life doesn't turn into an absolute nightmare,” Chapparo said. 

Chaparro said that while working at the Fallon hospital, there were many times when, because of a lack of foresight or an unintended situation, a baby would be born that the facility wasn’t equipped to treat.

“Sometimes there are situations that are just beyond control, which in the industry, we call ‘not compatible with life,’” Chaparro said. “But I just want [parents] to know that we're always doing the best we can to get the best outcomes for their kids.”

Thankful for the options

In 2018, Kallie and Sterling Johnson were living in Grangeville, Idaho, when, during an otherwise normal pregnancy, she felt as though she wet herself. Johnson said she wasn't extremely worried as she hadn't experienced any major complications when she gave birth to her son several years earlier. So she cleaned herself up and then went about her day. 

When it happened again, she called an emergency room doctor who said that she likely lost amniotic fluid that surrounds and protects an embryo while it is growing in the uterus and told her to rest and go into her doctor’s office the next day.

After some diagnostic tests, doctors determined the baby was sitting in less than 2 percent of what would be normal levels of amniotic fluid, and because Johnson was less than 24 weeks pregnant, there was nothing that could be done. 

Johnson was sent home and later gave birth to a stillborn girl.

“I've lost multiple other close family members and it's a different kind of loss,” Johnson said. “I would describe that as the worst thing I've ever been through.”

Though Johnson and her husband tried to have another child after the death of their daughter, she said it wasn’t until five years later, when they were living in Paradise Valley, Nevada, that she became unexpectedly pregnant. 

She said she was excited, but fearful, worrying whether she would get to the end of the pregnancy and if the doctors and hospitals in Winnemucca would be able to provide her with the care she needed.

Like the first time, Johnson lost amniotic fluid 23 weeks into her pregnancy. She and her husband rushed to the hospital in Winnemucca. She was then flown via helicopter to Renown, where doctors said they could help her.

“I thought, ‘This is crazy, I'm on a chopper just to go home and lose my baby again,’” Johnson said.

But when she reached Renown, there was a team of NICU specialists who made sure the baby was stable and gave her a “whole plethora of choices” that she could pursue, informing her of the potential risks, such as brain bleeding and infection resulting from a premature birth. 

After her husband met her at the hospital, they decided to try to save the baby. Eight days later, Johnson gave birth to her daughter Sloan, meaning “warrior” in Irish.

Sloan spent the next 160 days in the NICU receiving round-the-clock care from respiratory therapists, doctors and nurses. She had challenging days when Johnson wasn’t allowed to touch her, but the doctors and nurses were there to help, and Johnson said she stays in touch with them as best she can.

Now, nearly 2 years old, Sloan is described by her mother as an animal lover who likes spending time outdoors. The two spend most of their time together and Johnson helps Sloan with the feeding tube she relies on for nutrition and hydration.

Sloan has some medical issues that Johnson and her husband are trying to navigate, and they moved to Fallon to be closer to Sloan’s doctors. Johnson said she still thinks about her first daughter, wondering if she could have done something else to save her baby’s life.

“It's hard sometimes to choke down that guilt of like, ‘Why didn't I just get in my car and drive to Boise and go to a big hospital? Or why did I take one doctor’s word for it?’” she said. “I will always be thankful for the options that we were given to try with Sloan.”

This story was updated on 1/8/2023 at 5 p.m. to include that REMSA Health has access to a fixed-wing plane as of Dec. 29, 2023.