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It has been nearly two years since the global outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), causing Covid-19 in humans. In the first months of 2020, medical professionals around the globe scrambled to understand the virus and determine procedures and best practices to reduce and prevent its spread.
From the onset, however, it was abundantly clear that protecting front-line healthcare workers and those working alongside them such as air medical pilots must be a priority.
The very nature of their jobs, requiring close personal contact with affected individuals, makes these workers particularly vulnerable to infection.
“Many pilots were extremely fearful that they would contract the disease, or worse, take it home to their family,” said Brian Bihler, director of operations at Metro Aviation, which operates 160 aircraft for 39 air medical programs across the U.S.
“Some were vocal while others quietly approached flights with a level of hesitancy,” Bihler added. “Understandably, the distraction could easily divide their focus and attention on the job and the task at hand. To help mitigate these distractions, we formed an advisory panel of health experts to help us in creating protocols for our crew and relied on CDC guidance to arm pilots with the proper PPE [personal protective equipment] and facts about how to stay safe.”
“Initially, PPE was in high demand and in short supply. Pilots were initially restricted access to hospitals and patient rooms. Clearing this hurdle required numerous consultations with physicians to clarify procedures and ensure safety,” said Bihler.
Dr. Craig Bates, medical director at Metro Life Flight in Cleveland, a Metro Aviation program, said Covid-19 presented a unique challenge for keeping air medical crews and patients safe because policies and procedures in place to keep staff safe in a hospital environment don’t readily translate to the interior of a helicopter.
“We have had great success by bringing together a diverse collection of experts that are not only smart but also good listeners and good team players,” Bates said. “This included our hospital infection control medical director, the leadership for [Metro], our flight communications office team, and ongoing active engagement of our frontline staff. The result was an evolving set of guidelines and procedures that everyone had ownership of and was a part of creating.”
Tom Baldwin, vice president of safety for Global Medical Response (GMR) and a leader of the company’s national Covid-19 response, said it was important that operators clearly communicate how PPE would be used and how Covid patients were treated and transported. GMR’s portfolio of companies include Air Evac Lifeteam, REACH Air Medical Services, Med-Trans Corporation, AirMed International and Guardian Flight.
“Information sharing and community education became important to ensure that our communities knew we were still here for them and that the flight environment was safe,” Baldwin said. “Information was changing rapidly and frequently was contradictory between states and regulators and our ability to quickly receive, understand and provide clear information was a challenge.”
With the rapid onset of the pandemic, many operators faced supply chain shortages and delays for resources. GMR was able to successfully mitigate PPE shortages, but a tremendous amount of work occurred in the background to source and ensure that no counterfeit PPE entered its system, Baldwin said.
There was also concern ensuring PPE compatibility with flight helmets, night vision goggles and other existing safety equipment. In some cases, newly developed PPE did not meet certain certification requirements and was therefore unusable or increased risk to flight teams, Baldwin said.
“At one point there were dozens and dozens of new products flooding the market, all claiming to offer better protections against the Covid virus,” said Baldwin. “Many of these offered no real advantage over existing products but each had to be reviewed.”
Some operators sourced existing products originally intended for in-hospital care and adapted them for air medical. Utah-based Classic Air Medical (CAM) was one of the first operators in the country to employ a specially adapted Portable AirBoss ISO-POD aboard their fixed-wing aircraft to isolate suspected Covid patients. Due to the size of the pod unit, however, it was not ideal for use aboard helicopters.
Instead, CAM adopted helmet-based noninvasive ventilation (NIV), units originally designed for in-hospital respiratory
treatment. The helmets, intended for Covid-positive or oxygen-
dependent patients, were adapted to the air medical role. Their small size as compared to the ISO-POD made the system well suited for the working confines of the rotorcraft fleet.
In the early months of the pandemic, CAM crews adhered to strict PPE and aircraft decontamination protocols on every Covid patient flight. Even while transporting cases that were not Covid-related, patients and crews wore masks. In spring 2021, masking protocols were relaxed slightly when Covid cases began to decline. But with the recent surge of the Delta variant, strict protocols were reinstated.
One of the hardest hit Covid areas of the country has been the Navajo Nation, an American Indian territory covering over 27,000 square miles (69,000 square kilometers) across the American Southwest.
“We had a really significant drop in transport numbers in the very beginning [of Covid],” CAM chief administrative officer Wade Patton said. “But then it quickly transitioned to being very busy and now, our crews are becoming over worked at most locations, especially around the Navajo Nation. That’s where it’s really hitting hard.”
Many of the CAM clinical team work other jobs on their time off — full or part time work at hospitals or fire departments. But with the increased workload, especially on the Navajo Nation, many are not wanting or able to do both.
“Some people are just not into it anymore,” said Patton. “They’re getting their rears kicked in the ER and then coming to work for us and getting the same kind of intensity. So, there’s just a lot of folks who are not wanting to do it anymore. It is a reality for us. It’s having a huge impact and I think it’s across the board [air medical and hospitals].”
Other air medical administrators point to encouraging lessons resulting from the pandemic. “The Covid-19 pandemic has demonstrated how resilient EMS workers are in the face of adversity,” said Vicky Spediacci, air chief operating officer for the West at REACH/Guardian Flight. “We are approaching the second anniversary of this crisis reaching the United States, and our teams remain committed and engaged in helping their communities overcome.”
“The pandemic has also demonstrated how interconnected healthcare is in the United States. When there is a change in policy, practice or need, those impacts are felt industry-wide,” Spediacci added. “As a result, we have increased our communication efforts, engaged in even more proactive planning and strategy development, and have bolstered our efforts and refined our focus on PPE stores and infectious disease precautions and decontamination practices.”
In spite of all the lessons learned and encouraging signs, Spediacci acknowledges Covid continues to place a high demand and strain on all aspects of the healthcare system, including her clinical personnel.
“Our teams continue to put forth tremendous effort to ensure they can serve the needs of their patients and communities every day. That said, like many healthcare organizations impacts to staffing have been driven by exposure to Covid-19, loss of support services such as childcare and school closures, staff who choose to no longer be in the industry due to the risk and a reduction of qualified candidates with educational facility shutdowns.”
Dealing and Adapting
Billie Sell, clinical manager for North Memorial Health Air Care (NMH) said the seemingly ever-changing science early on in the pandemic was difficult to keep up with. With seven bases spread across Minnesota and Wisconsin, communication with team members was the biggest challenge, Sell said. Making sure everyone was up to date on the current PPE recommendations and patient care goals required daily emails and meetings.
“From the beginning we implemented Covid precautions for every patient transport, regardless of Covid status,” Sell said. “This required an N95 mask and safety glasses on every patient. We switched to Tiger Masks, to improve in-flight communication, as well as the continued protection. During the 2021 spring/summer, we relaxed the heightened precautions to just simple masks, instead of N95s on all patients,” said Sell. The Tiger Mask is a half-respirator mask for air medical/EMS/SAR flight helmets made by Tiger Performance.
“As far as operations, we haven’t changed our mission — to take care of our customers and deliver the ‘best care in the air,’” said Sell. “What has changed is the PPE required and the decontamination required after each patient. We worked hand in hand with our hospital team, the medical directors, and our aviation leaders to create workflows and implement safety measures that worked for everyone.”
Headquartered in Phoenix, Arizona, PHI Air Medical (PHI) transports more than 30,000 patients annually, operating out of 75 bases across the U.S. In the early days of Covid, PHI, like other operators, concentrated on understanding the virus and developing procedures for safeguarding crews while providing a high level of care for infected patients.
“Clinically, while we were already a strong program with handling complex vent settings, I think we took it to another level,” said PHI medical director Dr. Scott Van Poppel. “The degree of hypoxia and poor lung compliance we have seen with Covid, almost on a relentless level, pushed us to become even more familiar with high-level, and often rescue, ventilator settings.”
Van Poppel and his team strengthened their “nitric retrieval” program, enabling PHI to transport what previously may have been a non-transportable patient. The program has been expanded to other bases equipped with a Bell 407 or instrument flight rules-certified Airbus EC135 and can be accomplished with or without a doctor aboard.
“We backed this up with more advanced ventilator training and more hands-on time with an [intensive care unit] physician,” Van Poppel said. “In addition, Covid required us to think outside of the box and see what other options there were for transporting patients that we would otherwise not be able to transport.”
PHI also built an extracorporeal membrane oxygenation (ECMO) transport program, the first in the U.S. abord an EC135 helicopter.
“ECMO essentially does the work of the lungs and/or heart by oxygenating and circulating the blood, which allows them to rest and recover,” Van Poppel said. “In critically ill Covid patients specifically, their lungs become incapable of adequately exchanging gases, and thus require interventions such as ECMO to do that job while allowing the lungs to recover.”
“ECMO treatment is proving to be the real hero in caring for these critically ill patients, and having the ability to provide smaller community hospitals access to this treatment has become a game changer for some patients,” Van Poppel added. “These are truly the sickest of the sick. There have been some amazing success stories from the use of this treatment on patients that would not have survived without it.”
PHI regional director Chris Hardman said that as the pandemic has persisted, the company has innovated and evolved its services and the level of care available to patients.
“The knowledge and capabilities we have gained will continue to serve patients in the future,” Hardman said. “Notably, the EC135 helicopter makes up approximately 30 percent of the global air medical fleet. Implementing an EC135 ECMO program like ours can greatly expand patient access to lifesaving ECMO therapy.”
Covid in Canada
North of the border in Ontario, Canada, a provincial command center was established early on to track ICU capabilities to optimize “load-sharing” of Covid patients.
“This streamlined bed-finding, transport and patient tracking through all phases of transport [was] valuable to maximize efficiency given the volumes we were experiencing at times,” said Dr. Bruce Sawadsky, chief medical officer for Ornge, the leading medical transportation provider in Ontario. “At the beginning, we experienced many of the same challenges shared by healthcare providers everywhere. We were faced with a highly dynamic situation where staff guidance and procedures were changing frequently and rapidly.”
Ornge launched a Covid-19 operations medical committee with frontline involvement to discuss medical and operational issues through the pandemic, Sawadsky said.
“It was important staff were receiving the right kind of information, separating actionable information from noise, keeping staff informed but not overwhelmed. We completed regular virtual town halls for all staff as well as with individual groups, pilots, paramedics and non-operational staff,” he said. “We learned there is limited information available on engineering controls specific to ventilation and hazard control for the transportation of patients with communicable diseases in the aviation environment. This is critical as it informs decisions around appropriate PPE for pilots and paramedics operating in these aircraft. During Covid, this was especially important, as the ability to maintain non-invasive ventilation like high flow nasal cannula in transport was vital to avoiding invasive ventilation for a number of system and patient reasons.”
The lack of information on engineering controls and robust research on the risk of using aerosol generating procedures in aircraft led Ornge to conduct its own research on particle dispersion in flight. This allowed the company to determine appropriate PPE for staff, Sawadsky said.
As Ontario begins a fourth wave of increased case counts attributed to the Delta variant, Ornge is seeing relatively low ICU and hospital admissions due to high vaccination rates in the province, said Sawadsky. In turn, air medical call volumes have not shot up this time around, he said.
“The EMS community and specifically the HAA [helicopter air ambulance] community have learned and continue to learn as the pandemic continues to impact the country,” said Global Medical Response’s Baldwin. “Flight teams have been faced with many challenges and personal stressors. Some team members have left our family for fear of contracting an infection or simply through the personal stress of dealing with the impact of the virus on their communities and patient populations. Understanding the impact and providing the resources to support our teams is critically important.”
Metro Aviation’s Bihler said the Covid-19 pandemic has had far-ranging and potentially permanent impacts on HEMS operations.
“Today, you almost have to treat everyone as being Covid positive,” said Bihler. “Covid has changed the way that pilots and crews interact with patients. It has also changed pilot preparations. Increased PPE has led to complications with day-to-day gear.”
PPE can cause additional discomfort when wearing a flight suit in summer months, and wearing a mask inside the aircraft can cause NVGs to fog up, Bihler said. Aircraft must be decontaminated after a Covid patient is transported, leading to increased out-of-service time.
Spediacci, of REACH/Guardian Flight, said the virus has touched everyone in the air medical industry in some way and that the sector proved adaptable to a global emergency.
“As an industry, it has shown us the importance of planning, the need to be coordinated and organized yet to remain flexible when faced with rapidly changing situations or circumstances, and that clear, concise, and frequent communication is paramount,” Spediacci said. “It has shaped how we now look at infectious disease and has reinforced our policies and practices. Lastly, it has shined light on the valuable role air medical transport plays in the healthcare system and the inherent risks that come along with the profession.”
Covid likely will be a factor in human affairs for some time, said Patton, CAO at Classic Air Medical.
“I don’t know that it’s going to impact overall [call] volume and providers are going to go out of business. But I do see us always having this in our day-to-day operations. I think there’s going to be more operational issues but not necessarily affecting the success of the industry. I think it’s going to be something we’re going to have to deal with going forward but I think we’re better equipped to deal with it now.”