London 792: On call with Ornge

There can be few air medical organizations that have attracted quite so much media attention as Ornge, Ontario’s air medical transportation provider. The problems it had in upper management under the stewardship of former CEO Chris Mazza have been well documented, with various allegations of financial and organizational mismanagement splashed across the front page of the Toronto Star on more than a few occasions. With funding provided by the province, it was a political issue from the start. A report from the coroner’s office, hearings held by a standing committee in the Ontario Parliament, and an ongoing investigation by the Ontario Provincial Police (OPP) followed.

While the alleged malpractices were limited to some of those at the executive level — a group that was swiftly replaced — it sent a tremor throughout the organization. As its front line staff continued to provide the same life-saving service to the people of Ontario they’d always provided, they did so with the organization’s name and reputation being brought into question.

“I remember landing at places and there were actually hecklers at the fence, and they’d be like, ‘where’s our money?’ ” said Brandon Doneff, a paramedic at Ornge’s London, Ont., base. “Once in a while you’d walk by someone in the hall in the hospital, and they would say something. One time, we were just walking along a corridor, and an old man, out of nowhere, goes, ‘Thieves!’ What do you do? You just keep walking.”

With a new executive in place, and sweeping changes to the company’s organization being made, Ornge invited Skies to take a look at its inner workings. We were presented with unprecedented access to the new Ornge’s Mississauga headquarters and its base in London to get a feel for how the company is progressing. The result is this special two-part report. In this first instalment, we focus on what it’s like working on the front line with the Ornge crews in London. Then, in the following instalment (featured in the next issue of Vertical 911), we’ll focus on the organizational changes the company has made as it seeks to chart a new path for air medical transport in Ontario.

London, Ontario. The Forest City. Situated about halfway between Toronto and Detroit, and an urban center in its own right with a population of about 350,000, it’s far enough from both to be surrounded by swathes of idyllic farmland that reach up to Lake Huron in the north, and Lake Erie to the south. This provides a good mix of the urban and rural for the crews of London 792, the Ornge air ambulance that’s based to the northeast of the city at its international airport. 

As I found during my recent visit there, the hangar itself is hard to miss. Turning onto the airport’s Hurricane Drive, an enormous Ornge logo beamed out through the early morning light.

Meeting me at the door was Ian McLean, the base manager for the London location — and a former Canadian Forces Snowbirds pilot. After a warm greeting, McLean gave me a brief tour of the facility and introduced me to the crew.

Ornge is a round-the-clock service, and covers that by running two 12-hour shifts each day — 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m. I would be joining the day crews, and, as I arrived, the departing night crew was collecting their things and getting ready to head home.

At the London base, each shift begins with an air medical resource management (AMRM) meeting, and attendance is compulsory. Representatives from each division discuss their current work and any major issues, encouraging a free flow of information and communication at the base. It’s one of the operational practices re-introduced by McLean following his arrival at the base. “I’m just used to the military, where there’s a briefing every morning,” said McLean. “So I just said we’re going to have shift briefings, and we’re going to call them AMRM. They’re pretty much shift specific, but we also get into bigger issues as well. It’s been really good to have that because we get the cross pollination between the paramedics, engineering and pilot groups.”

Following the meeting, during which it became apparent that the weather wasn’t looking promising, people went about their business as we waited for a call to come in. The maintenance team was kept busy completing a 1,200-hour inspection on one of Ornge’s fleet of 10 AW139s (another aircraft was at the base ready for flight); while the paramedics and pilots hit their respective books. One of the paramedics took the opportunity to use the gym that takes up one small corner of the hangar. Despite the fact that there was no call to attend, no time was being wasted.

The minutes dragged on, and then turned to hours. I waited as patiently as I could for the moment we’d all be springing into action. “It’s that all or nothing,” said Darin Higgon, the captain of the aircraft for my two shifts. “This is the hard part of the job, is the hanging around and being on standby. Everyone’s into their books or doing other things. I’m the training captain for the base, so I’ve always got little side projects going on. We’re working on training programs or updating some of our manuals or training procedures or things like that.”

Day one ended without a call, and while I was happy the people of southwestern Ontario were keeping out of trouble, I was keen to see the Ornge crews do what they do best. As it happened, I didn’t have to wait too long on day two to see them in action.

The call came in at 10:10 a.m. As with all call requests, the case details were held until the pilots had completed a weather check and approved the flight. One of the pilots then headed out to get the aircraft ready, while the other told dispatch they’d accepted the call, and was given a flight number, a patient number, and the weight and gender of the patient.

We boarded the aircraft, and set off over sedate golf courses and sprawling farmland east to the city of Guelph. However, only a few minutes into the flight and we were switched to another call in the remote community of Hagersville, about 20 minutes away. It’s a triage decision taken by the doctor in charge of prioritizing the service’s transports. This new call required taking a 20-year-old unconscious man to Hamilton. Information gradually filtered through to the paramedics in the cabin: the patient had possibly suffered a head injury, and was found near an industrial area.

In the next few minutes, the paramedics troubleshot scenarios they might encounter as further information drifted in: the patient had a seizure, but was now somewhat responsive.

A small and scattered group of onlookers watched us arrive at the helipad next to the small rural hospital. Brandon Doneff and Bryan Stevens, the paramedics on the flight, split the duties on arrival in the ward: Stevens began assessing the patient while Doneff organized the paperwork and took what information the receiving paramedics and the attending doctor could provide. The pair then worked as a team to package the patient for transport.

We were back in the air just after 11 a.m. for the short flight to Hamilton General Hospital. Once on our way, Doneff told me they’d discovered the patient had a history of seizures, and they were fairly confident he hadn’t suffered a head injury. 

Nevertheless, he would be getting checked out by the team at the trauma center.

Flying over the clifftops of the Niagara escarpment with the city of Hamilton appearing below and Lake Ontario beyond it, we soon landed at the hospital’s rooftop helipad, where a security guard waited to escort us down the elevator. Stevens chatted to the patient, who had become quite responsive, as we worked our way through the ward. When we reached the team of nurses and student doctors waiting to receive us, Doneff gave a brief outline of situation; once the patient was moved from the stretcher to the bed, he read the full case information to the group.

At this point, my attempt to be an invisible observer failed, as the doctor in the charge of the group said, “For the record, I love the Ornge operation!”

“Do I detect sarcasm?” said Stevens with a smile. 

“No, I really do!” was the reply.

With the patient set, and paperwork complete, we were on our way again. As we waited for the elevator back up to the helipad, a middle-aged woman nervously approached Doneff. “You’re the helicopter guy?” she said.

“Well, I’m one of them,” he said.

“It gave me such a good feeling to see you come in – that you’re out there helping people. Keep it up!”

Doneff thanked her, and after she left, broke out laughing. “Oh, that happens all the time…”

As we headed back towards London, a request for a scene call in Guelph came in over the radio. A couple of minutes later, however, it was cancelled. Perhaps the land paramedics decided the helicopter wasn’t the most appropriate form of transport, the paramedics noted. Perhaps the patient was beyond help. 

We turned our heading back towards London.

Back at the hangar, we had time for a couple of slices of pizza before the phone went again, and we were back in the air. It was a scene call in Barrie, and the only information we had is that it was for a man with a hand caught in a machine. Half an hour into flight, we found out it was a 30-year-old man, and that he had hand fracture —but a couple of minutes later, we were called off.

The paramedics said the amount of information they have can vary enormously between calls. “Sometimes it’s a bit of a mystery,” said Stevens. “It’s an art, and you’re almost like a detective.”

Reflecting on the morning’s call, Doneff said, “Did the guy have a seizure and knock his head — or knock his head and then have a seizure? Well, it turned out it was neither…. Bryan was checking for toxins because the patient had white powder on his pants. You’re piecing it together — what do we already know? How did we get here?”

Like the rest of the team in London, I tried to be productive during the periods of downtime while at the base. During my first shift in London, I spoke with Dr. Keith Donovan, who was there in his capacity as an Ornge transport medicine physican (TMP) — or “doc in the box” as they’re known to the rest of the crew — to learn more about the process behind the scenes.

Most of Ornge’s TMPs are also emergency room doctors, so have a depth of experience dealing with trauma. Although spread throughout the province at the company’s various bases, there is only one transport medicine physician on duty at any one time, and that person will have responsibility for all of Ornge’s transport medicine across Ontario. 

When a call comes in, it will have a level of care and urgency designation assigned to it, based upon the data that has been entered at Ornge’s dispatch center. The doctor’s first job is to check whether those designations are appropriate and, if there’s more demand for transport than resources available, they will also triage the calls — deciding which patients get moved first.

Once the level of care and urgency have been assigned, it’s a matter of looking at which aircraft can respond the quickest with the appropriate level of care. (The aircraft’s level of care is based on the level of the paramedics inside. In London, all the full-time paramedics are critical care paramedics — the highest of three levels of care — giving them a broader spectrum of medical directives and standing orders under which they can operate, and more medications they can administer.) 

Most of Ornge’s transports are inter-facility — or hospital to hospital — transfers, and for the majority of these, there is usually a good amount of patient information available when the call comes in. “The trauma scene calls are much more limited,” said Donovan. “We’re dealing with 911 information, and often it’s something like: ‘MVC vs car; one patient trapped; delayed extrication; patient conscious.’ And that’s it. That’s all we’ve got.”

Once patient contact is made — whether it’s at a trauma scene or in the hospital, the paramedics will call the doctor to discuss patient care, and to receive further orders.

“Ultimately the paramedics are our eyes, ears and hands on site,” said Donovan. “I think that they certainly put a lot of trust in us to give them good advice, but we equally put a lot of trust in them to give us accurate information and carry out the care that we’ve agreed to.”

Brandon Doneff has been working in air medical transport for almost 20 years. A critical care paramedic, he is also the London base’s field training officer. He said the biggest challenge of the role is the sheer dynamics of moving a patient. “It’s all the radio work, all the paperwork, all the stuff above and beyond the medical side,” he said.

From an outsider’s perspective, it’s hard to get a grasp of how paramedics process all the information they may see at any given scene, but Doneff described it as a matter of working through a mental checklist. It begins with a primary assessment of a scene to ensure its safety. “The most important person on scene or is you — the care provider,” he said. “Because if you get sick or injured, then what?”

It’s then a matter of working through the checklist — airway, breathing, circulation, and so on. “It’s almost like you’re like a detective, because sometimes you can see that there’s the car [and] there’s the tree — he hit the car into the tree,” said Doneff. “Other times you go there and you’re like, ‘What happened? Oh, there’s a bottle of pills. OK, are those his pills? No. Well, how many pills are in there? Two days ago there were 50, and now there’s none. So maybe they ingested this…’ You have to get every check off that list in order to figure out what’s going on.”

Doneff said working in air medical transport was a fantastic career, but he wouldn’t necessarily call it rewarding. “I’m not looking for a pat on the back every time, because that’s just not who we are in this agency. We’re not looking for the public to know everything that we do. We don’t want them to know everything that we do — even though they want to know about the train wrecks, or the people who’ve been impaled by posts and eviscerated. But you just move on, say, ‘Yeah, that was a bad scene,’ think about the next day — and leave it at work.”

Darin Higgon, the training captain at Ornge’s London base, has been flying air medical aircraft for over 10 years. He is one of 10 pilots at the base, who average about 300 flying hours each per year. He said captains generally enter the job with 2,000 hours, whereas first officers will have 500 hours, with instrument flight rules (IFR) and airline transport pilot licenses. They arrive from a variety of backgrounds, from remote bush operations, to working over dense urban environments for news organizations.

Higgon said the appeal of the job was its intellectual challenge. “We maintain a high technical standard and flight proficiency,” he said. “We might not be doing as technically demanding flying as someone in the bush doing precision slinging. . . . [But] we need to be ready to go anywhere at any time, in busy airspace with too many airfields to count and all kinds of NOTAMs [notices to airmen]. We don’t have time to sit down and look at our route for 30 minutes before we depart on a flight; we need to be able to go and do it on the fly.”

While the aircraft has the capability to go IFR, Higgon said the preference was to go visual flight rules (VFR)where possible. “If we can go VFR, we do. Once you’re up IFR in the system, getting redirected is a real pain — and we get redirected all the time to more critical calls. With VFR, we can just turn, instead of taking five minutes to sort it out with air traffic control.”

I asked Higgon about the pilots’ distance from the medical team at the hospitals. Was this a conscious thing? “There’s this philosophical separation between the front and the back, where our job is to safely operate the aircraft — and that’s it,” he said. “The paramedics’ job is to take care of the patient — and that’s it. We have to work as a team, but we also try to maintain this separation.”

For this same reason, when a call comes in, the flight team are typically only asked if they can fly from point A to point B — they are not told what for, “because it could change your thought process,” said Higgon.

As for the effect of the media coverage on those working on the front line, he said it had changed little about his job. “The only thing that I think that might’ve gotten lost in all the media attention is that we’re still out there doing what we’re supposed to be doing every day. The system is pretty effective and we are making a difference.”

Among the changes made by the new executive group at Ornge is the installation of cross-functional base managers (previously the base managers had been focused on the medical side of the operation). Ian McLean assumed the role in London last November. 

“The two things that surprised me when I got here was how good a company it is, based on salary, time off, benefits, work hours, and the kind of equipment that you’ve got,” he said. “The one part I certainly wasn’t surprised at was the kind of people that are here — they’re exactly the kind of people that I thought would be here. They’re professional, they’re motivated, and they’re really smart — but I hadn’t anticipated how negatively they’d be impacted by everything they’d been through.”

For McLean, increasing the levels of communication — both internally at the base, and externally with head office — was a good place to start. The result is the daily AMRM meeting.

“We’ve really focused on flight safety, safety in general, and communications — those were really pillars that the operational mission is based on. . . . I can’t take a lot of credit, it’s just a matter of noticing what’s going on and then making a few subtle changes here and there. But those subtle changes have grown and have made a pretty big difference in London.”

As far as the public and media perception of Ornge is concerned, McLean is keen to turn the page. The upcoming CAE cup, in which air medical transport teams from across North America use the latest in patient simulation to display their real time critical care skills, could provide a real boost for the base — two of its paramedics (Brandon Doneff and Brad McArthur) are traveling to Nashville, Tenn., to take part. “The fact that we’ve two guys from this base chosen to represent Ornge at the CAE cup is a big deal,” said McLean. “I’m hoping they do really well, because that would do wonders for all of Ornge.”

Asked how he would describe the organization, McLean unhesitatingly said, “It’s a vital service — I just don’t know if enough people in Ontario understand what it is that Ornge brings to the game, day in, day out.”