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Helicopter air ambulance operators are weighing the risks of transporting patients who test positive or are at high risk of carrying the novel coronavirus, and are enacting rigorous safety measures to protect pilots and medical crews from the virus as it continues to spread worldwide.
Because the virus is so contagious, most emergency medical services are transporting patients by ground in specially outfitted ambulances with contained, filtered air circulation and physical separation between drivers and paramedics in the back.
In most helicopters, there is no physical separation between the cabin and cockpit, making it more difficult to contain contagions, according to Tom Judge, executive director of LifeFlight of Maine.
“For all of us that have specialized ground ambulances . . . we’re preferably moving these patients on the ground,” Judge said. “It is very difficult to effectively have personal protective equipment like an N95 mask, a face shield, goggles, protective gown or operating suit for splash protection and have that over a flight suit, under a helmet, using night vision goggles.”
Some operators have decided the risk to crews is too great and declared they will not transport any patient that has tested positive for coronavirus or the disease it causes, called COVID-19, according to Michael Benton, a HEMS pilot and aviation safety consultant. Among operators that have decided to transport high-risk patients, many have agreed on a set of precautions for pilots and crew.
To decrease the risk of transmission between cabin and cockpit, many operators are limiting coronavirus patient transport to helicopters equipped with night-vision goggle curtains that shut out non-modified lights in the cabin from flooding the cockpit. That would include models with a bulkhead between the two compartments like the Airbus H135 and H145, Leonardo AW109 and Bell 407, among others. It is more difficult to compartmentalize open interiors found in aircraft like the Airbus H125 or H130, Benton said.
Benton had surveyed five HEMS operators with a total of 33 rotorcraft and five fixed-wing air medical aircraft when he spoke to Vertical. Those split about half and half between operators who would not carry suspected or confirmed COVID-19 patients and those who would, as long as the patient was on a closed-circuit ventilator.
Those operators that had decided to take the risk enacted similar policies, including requiring employees to check their temperatures before even coming to work and avoiding coming in with a temperature higher than 100 F (38 C). Most are banning some international travel and cruise vacations for employees.
All are requiring pilots to wear an N95 respirator mask on any call where a patient could potentially be infected with the virus and male pilots must trim facial hair to ensure a proper fit. Some are requiring the removal of all facial hair because the virus is known to transmit inside water droplets and other particles that can stick to facial hair, Benton said.
Generally, hospitals that carry their own certificates and have authority over HEMS operations are “ahead of the curve” on safely responding to coronavirus patients, Benton said.
LifeFlight of Maine has set up standard operating procedures where ground transportation is the primary response if there is any way possible, even over long distances, for patients at high risk of COVID-19. Every call that comes in is screened for severe respiratory distress, a major symptom of the viral disease, Judge said.
“Up front, we’re screening any calls that come in for severe respiratory symptoms,” he explained. “We’re expecting we’re going to see one of these a day.”
Hospital-based doctors gather as much information on the patient as possible to determine if the patient is at high risk of COVID-19 and whether the underlying illness could be something less virulent, like asthma.
LifeFlight of Maine operates Leonardo AW109s and a KingAir B200 fixed-wing ambulance in an area with many populated islands and long distances between patients and hospitals. They have put in place screening procedures to determine the optimal and safest form of transportation for each patient, based on symptoms and the likelihood they have been exposed to or infected with the virus, Judge said.
“For most of these patients, there is no way that we can know for certain that they are positive for COVID-19,” Judge said. “Still, all the pilots have gone through training. We’re doing a lot of work with decontamination.”
Aside from the very real risk of infection, flying a patient at high risk of exposure to the coronavirus carries the risk of flight crews transmitting the virus to other crew members, hospital staff, their families and others. To mitigate the possibility of spreading the virus, if crews were to transport a COVID-19 patient, they would have to be quarantined and taken out of service, Judge said.
“Due to geography, we need every crew to be able to manage every patient. We do not have the luxury of setting up a dedicated [infectious disease] team and dedicating a single aircraft for potential [COVID-19] patients,” Judge said. “If we transported a high-risk patient by aircraft because that is what we really need to do for the patient, we of course will do that, but very likely we would then lose that crew to quarantine.”
In Scotland, where there are many islands off the mainland without intensive care units, the country’s health secretary Jeane Freeman confirmed on March 18 that the Scottish Ambulance Service has been chosen to fly coronavirus patients in need of intensive care to hospitals on the mainland, according to Shetland News. Prior to the announcement, it was uncertain whether the military would carry out the task. While there were initial concerns about personal protective equipment for crews flying with these patients, Freeman said those concerns have been resolved.
Metro Aviation, one of the largest HEMS operators in the U.S., has sent detailed guidance to its flight crews, who work with hospital-provided paramedics and physicians. The company has formed a team of advisors, which includes medical and program directors and chief flight nurses, to evaluate the need and precautionary steps required should they come in contact with COVID-19 patients, Metro spokeswoman Kristen Holmes told Vertical in an email. The company also tweeted a message regarding coronavirus on March 18.
Metro has directed pilots to practice diligent hygiene by washing their hands often and wearing an N95 mask, nitrile or latex gloves and eye protection whenever transporting a known or suspected COVID-19 patient, Holmes said.
Because Metro does not employ medical crews, it is only giving guidance to pilots and then sharing that guidance with its customers. Holmes said the company is following all U.S. Centers for Disease Control and Prevention recommended precautions.
“We’ve asked that our pilots refrain from entering health care facilities, and if it’s necessary, they should wear gowns,” she said. “They are not to assist in the loading or unloading of any confirmed positive COVID-19 patients and will adhere to the [personal protective equipment] requirements when assisting in the loading/unloading of other patients.”
“Pilots are not to participate in the decontamination of the aircraft’s patient carrying areas and we’ve asked for doors to remain open for as long as possible to allow fresh air to flow through the aircraft post-decontamination,” Holmes added. “Pilots are to clean all cockpit surfaces handling or touched, while wearing gloves and eye protection.”
North of the U.S.-Canada border, HALO Air Ambulance, which is the only dedicated medevac program to serve the entire region of southern Alberta, is still actively responding to calls, but has implemented “enhanced infection control precautions,” according to chief executive Paul Carolan.
In the event HALO responds to a scene where a patient has risk factors associated with coronavirus and COVID-19, the operator has put protocols in place to protect its flight and EMS crews, Carolan said.
HALO flight crews and aircraft have been isolated, public relations events have been postponed or canceled, and it has begun a public-service announcement campaign asking emergency service partners at accident scenes to stay at least five meters from aircraft and flight crews.
Operating an Airbus BK117, as well as a Bell 206 as a back-up aircraft, HALO works closely with Alberta Health Services, which operates ground ambulances and provides flight paramedics to HALO.
That partnership, and a relationship with an international air ambulance service, “allows us to implement precautions at an extremely high level,” said Steve Harmer, chief pilot/operations manager at HALO. “HALO Air Ambulance has always had a protocol for infectious type disease in the event we are required to transport a symptomatic patient, but these circumstances are extreme.”
The latest update on the Government of Canada website indicates there are currently 119 confirmed cases of COVID-19 in the province of Alberta; while it’s possible that HALO could receive a call for a patient who has been exposed to the coronavirus, Carolan said “at the moment, transporting a patient known to have COVID-19 would be extremely unlikely, and we would be told by our EMS partners if that were the case.”
In the meantime, Helicopter Association International (HAI) on March 16 circulated tips on decontaminating helicopters and reassuring customers that aircraft are virus-free. HAI posted a “COVID-19 combat checklist” on its Facebook page to encourage operators to take necessary sterilization steps.
The checklist recommends that between flights crews wash their hands and any exposed body parts; sterilize aircraft components such as door handles, seat belt buckles, flight controls, and absorbent fabrics; and sterilize flight equipment such as headsets, helmets, mic booms, and mic muffs.
Though COVID-19 is a unique pandemic, HEMS operators have not altered the basic “go/no-go” rules of flight safety and the virus ranks equally with weather and other factors when deciding whether or not to make a flight, said Judge of LifeFlight of Maine. His insistence that safety is paramount, now as ever, was echoed by all the operators and officials Vertical contacted.
“If people don’t believe they can accomplish the job safely, then we would expect that they would say ‘No’ and we would support that decision and find another way to transport the patient,” Judge said. “We still need to take care of patients, but we don’t want anyone to put themselves or their families [at risk]. … You can protect yourself. You can protect your colleagues. You can protect your family. And you can protect the patient. We’re really looking at it in that order because we can’t provide safety to the patient if we don’t have the whole system safe behind them.”