Canada’s air medical transport providers say collaboration, communication are keys to pandemic response

As news of the novel coronavirus – first identified in Wuhan, China in late December – began to percolate its way through the mainstream news media, a few staff members at Ornge, Ontario’s air medical transport provider, began to take notice.

Ornge's fleet consists of eight Pilatus Next Generation PC-12 aircraft and 12 Leonardo AW139 helicopters. Mike Reyno Photo
Ornge’s fleet consists of eight Pilatus Next Generation PC-12 aircraft and 12 Leonardo AW139 helicopters. Mike Reyno Photo
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“It piqued our interest quite early on, since many of us had been through SARS [in 2003],” said Justin Smith, chief flight paramedic. “We began to figure out what PPE we had and what would be required to move forward.”

Canada’s first case of the novel coronavirus, later named COVID-19, was reported on Jan. 15, 2020. Subsequent cases occurred gradually through the end of February, all among travellers who had returned to Canada from countries affected by the virus. The number of Canadian cases increased sharply in March, and that’s when Ornge activated its pandemic plan.

Smith was outlining the organization’s response during a webinar hosted by the Association of Air Medical Services (AAMS) on April 21. Moderated by association president and CEO, Cameron Curtis, the discussion was billed as a town hall meeting focused on the Canadian air medical community’s pandemic response. In addition to Ornge, representatives from Shock Trauma Air Rescue Service (STARS) and B.C. Emergency Health Services (BCEHS) participated in the panel.

Ornge, which operates 13 bases across Ontario with a mix of rotary, fixed-wing and land-based patient transport assets, has so far moved 209 confirmed or suspected COVID-19 patients. Overall, 57 per cent were moved with land vehicles, 24 per cent with the Pilatus PC-12 fixed-wing fleet and 19 per cent with its Leonardo AW139 helicopters.

So far, the total number of missions Ornge is performing has dropped by about 35 to 45 per cent across the board. Medical director Dr. Michael Peddle attributed that decrease to the cancellation of non-urgent elective procedure transports as well as about a 10 per cent decline in urgent cases compared to last year.

Communication has been critical to developing Ornge’s pandemic response.

Smith said a joint clinical/operational committee has been formed and meets daily to tackle questions that come up about personal protective equipment (PPE), for example, or the way paramedics carry out clinical procedures.

Added Peddle: “We discuss active challenges within the fleet. We write operations clinical guidelines – a living document for all frontline staff including aviation AMEs [aircraft maintenance engineers] and paramedics. It outlines operational management processes, PPE, decontamination etc. One of the things we’ve found very important is communication with frontline staff.”

Ornge has implemented weekly town hall meetings for all staff, where some clinical and operational information is provided and questions are answered. In addition, an internal web page provides further resources.

“From a process perspective, we’ve made some changes to our pairings and our staffing to make sure we have capacity if we have issues with our workforce being sick or unable to attend work,” said Peddle. Overall, staffing has been adequate to this point, but Ornge has built a plan for surge management to help it meet the needs of communities across Ontario, if required.

While all Ornge employees are screened when they come to work, the patient transport provider has also rolled out some additional skills, said Peddle, including prone ventilation and expanded rapid sequence intubation.

A standing item on the organization’s checklist is an evaluation of current PPE standards. Ornge medical staff wear gowns, gloves, face shields and eye protection, in line with Ontario guidelines.

“One of the mainstays of our approach has been do what you know and do it perfectly,” Smith commented. “We instituted PPE donning and doffing checklists and created a PPE utilization flowchart. As we know in transport medicine, where you don and doff your PPE can vary. We found the flowchart reduced anxiety because it provided rules, including for the pilot group.”

While fixed-wing pilots have a high rate of PPE “burn,” it’s much lower with rotary-wing. Helicopter pilots don’t usually have to help with patient onboarding due to the AW139’s self-loading stretcher system.

Two of STARS’ new Airbus H145 helicopters fly past the air ambulance’s iconic BK117, which will soon be retired. STARS said it has seen decreased mission volume during the COVID-19 pandemic. STARS Photo

Keeping safe is the priority

Ornge is not the only air medical provider who has noticed an overall drop in missions during the pandemic.

STARS operates a fleet of Airbus H145, BK117 and Leonardo AW139 helicopters from three bases in Alberta, two in Saskatchewan and one in Manitoba. STARS has been slowly acquiring new H145 aircraft since April 2019, and plans to replace its BK117 and AW139 fleet with a total of nine H145s.

“We’re actually seeing a decreased mission volume,” said Dave Evans, senior director, Clinical Services, STARS. “We’re still transporting urgent patients, the typical heart attacks and strokes we would typically transport. ILI [influenza-like illness]-type transports account for 13 per cent of mission volume right now.”

Fortunately, COVID-19 spread in Alberta, Saskatchewan and Manitoba has been below some of the predictive models, he added, and hospitals aren’t necessarily overwhelmed yet. STARS has so far transported two confirmed COVID-19 patients since the numbers shot up about a month ago.

“With the cancellation of pro sports . . . things got really busy within that first week, with the amount of info needing to be shared and the learnings coming out from Europe and China,” recalled Evans.

“It became evident we needed to start a small group just to field all those questions from our crew. So we started the COVID Communications Working Group right away. Our role was to support our chief medical officer to make sure we’re following best practices, medical evidence, provincial guidelines across the three provinces. Keeping safe was the priority.”

The working group has been sending out frequent communications, both written and video, twice a week.

STARS is lucky to have 100 per cent staffing right now, despite a dip in the beginning of the pandemic related to mandatory post-travel isolation. Staff are currently checked for symptoms before each shift, including temperature screening, with documentation required before crews can enter hospitals.

Luckily, PPE procurement has been relatively painless and the organization is adjusting usage parameters in accordance with emerging evidence.

The COVID Communications Working Group is being led by Dr. Jamin Mulvey, incoming STARS Calgary medical director, who also participated in the webinar. He was working in the U.K. with London Air Ambulance and returned to Canada early in the pandemic.

“The biggest challenge is that with a lot of information out there, it’s rapidly changing practices and emerging guidelines,” said Mulvey. “We’re dealing with a lot of opinion and low-level evidence, and we’re trying to sift through it effectively and make robust guidelines for our group.

“Some areas that have been a little bit challenging is the discussion on what exactly is an AGMP – or aerosol generating medical procedure – and with non-invasive ventilation strategies, what are the relative risks of AGMP compared to, say, intubation.”

STARS has moved away from non-invasive and high flow procedures on its helicopters unless absolutely necessary, based on very strict guidelines and discussion with the on-duty transport physician.

Procedures are constantly being evaluated and adjusted where necessary, for both medical staff and flight crews.

Jenny Thorpe is a flight nurse who handles stocking and preparedness ordering for the STARS base in Saskatoon, Sask.

“Being on the front lines and directly involved in patient care, it’s been a learning curve for myself and our crews,” she told the group. “A month ago, there was a high anxiety level. But we’ve worked as a group and with our leadership, just taking it one day at a time and realizing this isn’t a fast process. It’s a journey that won’t be over quickly.”

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Thorpe said the team has found success by focusing on the little things that will keep them safe during a mission, such as following strict PPE donning and doffing procedures for medical crew as well as pilots.

She is also an advocate of practice drills. “You can talk about PPE and being prepared, but if you haven’t prepared and simulated it, you’re going to miss steps. I encourage everyone to simulate caring for a COVID patient.

“It’s about slowing things down, making sure you’re making your decisions with purpose and not reacting.”

BCEHS said it has noticed call volumes have declined by roughly 30 per cent since the start of the pandemic. BCEHS Photo

There is no emergency in a pandemic

In Canada’s westernmost province, the BCEHS team is following the same steady, purposeful path.

“When we’re doing a call, we’ve emphasized there is no emergency in a pandemic,” commented Dr. Steve Wheeler, BCEHS medical director, Critical Transfers and Aviation Medicine. “It all comes down to crew safety. We don’t rush into it; we plan and make sure everything is set up. We don’t run positive pressure other than intubation. If the patient needs to be intubated for the flight, our threshold is very low, we’ll have them intubated in the sending facility. We try to methodically plan out the whole trip.”

With six air bases throughout the province, BCEHS has also noticed call volumes have declined by about 30 per cent.

“We’re not doing the regular amount, we’re doing one to two COVID transfers per day that are spread between rotor, fixed-wing and ground transports,” said Wheeler.

He said the B.C. team’s Australian manager established a network of about 15 global air medical organizations early on in the process. They met three times a week by Skype “to try to prepare for PPE, crew safety, medical procedures, how to ventilate or oxygenate patients in flight, etc. That was extremely helpful for us.”

To prepare for a possible surge, BCEHS paused its paramedic training and released the instructors for work, placing some senior and junior students into station support roles.

The organization examined available PPE options and decided to adopt Tyvek suits, which has decreased the PPE “burn” rate. The service also purchased 3,000 silicone half-mask respirators with reusable canisters and face shields.

Educating its pilots was a high priority for BCEHS. They were heavily trained on donning and doffing PPE; they wear gowns instead of Tyvek suits.

Wheeler said the pandemic has delivered several lessons to the province.

“For us, this has highlighted to government and health authorities the need to improve and increase the capacity of our inter-facility transfers. Government announced yesterday they will provide five new aircraft. In every pandemic or catastrophe, sometimes there is opportunity.”

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