Air Ambulances in a COVID-19 World

Air medical operators reset best practices and protective measures in the fight against an insidious pandemic.

In just a short time, the world has quickly become familiar with medical teams attired in full PPE (personal protective equipment) fighting to save lives in crowded hospitals. Helicopter air ambulance operators are also responding to the new normal of life during the Coronavirus Disease 2019 (COVID-19) pandemic, as they look to save lives on two fronts: their patients and their personnel.

An Initial Lull

When COVID-19 began to spread across the United States in late January 2020, air ambulance services experienced an initial deep drop in volume.

“One of the first things that happened is everything ground to a halt, which interestingly enough happened after 9/11, too,” says Tom Judge, executive director of LifeFlight of Maine, which operates three bases in the state. “The bottom dropped out for air medical, with a 50% decrease in volume—for both scene and interfacility transport.”

Jerry Splitt, Geisinger Medical Center’s program director, saw the same thing about his six bases across Pennsylvania. “Our volumes were consistent—and even on the increase. Then, suddenly a decrease. You know, they say the medical industry is recession-proof, but it’s not pandemic-proof. Reduced transports and procedures cut income.”

Although some of the decrease was attributed to the halting of elective procedures, another large contributing factor was stay-at-home orders issued by local governments. Fewer people on the roads and out being active leads to fewer trauma accidents requiring air transport.

Paul Schaaf, pilot for emergency medical services operator STAT MedEvac, experienced a decrease in pediatric transports for the same reasons. STAT MedEvac coordinates the operation of SkyBear, the rapid helicopter transport service of Children’s National Hospital in Washington, D.C.

“I’m attributing [the decrease] to the kids not being in school or preschool catching the flu and other respiratory issues we used to fly them for,” Schaaf says. “They’re also not out in the woods or doing other activities that cause accidents, like snakebites, broken bones, etc. Parents are keeping kids close right now.”

Oddly, a sudden reduction in heart attack and stroke patients occurred at the same time, something that was also experienced after 9/11. These patients picked up again about the time the number of serious COVID-19 patients needing transport began to take off.

“To be perfectly honest, I don’t know what causes this phenomenon,” says Rick Rohrbach, EMS Director at Cooper University Health Care in Camden, New Jersey, about the sudden reduction in stroke and heart attack victims. “Maybe it’s because they were suddenly sitting at home on the couch. But the decrease … only lasted a few weeks.”

Sure enough, a few weeks into the stay-at-home orders, the scene changed. Typical respiratory-, heart-, and stroke-­related transports began to increase right about when COVID-19 patient transports began in earnest.

“We’re back to comparable volumes now, with COVID patients making up the difference from reduced trauma accidents,” says Rohrbach.

Preparing for Battle

Even before stay-at-home orders were put in place, many air ambulance operators began to prepare for the changing environment surrounding COVID-19. The universal first priority was to initiate procedures to protect the health of  crews so they could safely continue to save lives.

“The political narrative in the beginning of this crisis was confusing, with conflicting advice, but we’d been preparing for this since January, regardless,” Splitt says. “In the medical field, you can’t overplan for a pandemic, and we were very fortunate to have some warning and time to prepare.”

Specific policies and procedures instituted to protect crews from COVID-19 vary slightly between operators, based mainly on location, access to PPE, and medical facility direction. The biggest factor driving these differences stems from how each service is organized. In some cases, when an aviation service provides the aircraft, pilot, and mechanic, that service dictates procedures for its employees while the medical facility oversees procedures for the onboard medical staff. In other cases, the medical facility takes the lead in implementing overall health protection procedures.

Several preventive best practices were adopted across the industry almost immediately as a result of considerable collaboration between medical facilities and helicopter operators. The most common is the requirement for PPE for medical crews and pilots. In most cases, the medical crews wear full isolation gowns, N95 masks, face shields, booties, and gloves, while the pilot often wears an N95 mask and, in some cases, gloves.

Some operations require this level of preparedness only for transports involving known or potential COVID patients; others require it for every transport. Again, directives differ based on location, rate of COVID infection in the community, and PPE supply.

Unfortunately, with a worldwide PPE shortage, some operations are forced to ration their use of PPE based on whether a patient has tested positive for COVID or has the potential to be positive. Some are forced to wear masks for eight hours rather than dispose of them between patients.

N95 masks themselves pose an issue. The US Occupational Safety and Health Administration requires every user to be fitted for the masks and signed off by a medical doctor because the mask can restrict airflow. This requirement led to delays in many aviation service provider pilots receiving N95 masks, as overwhelmed medical staff prioritized their medical crews, according to Kenny Morrow, COO of Metro Aviation in Shreveport, Louisiana.

Other common protective measures that were initiated with COVID-19 include bagging in plastic everything on board the aircraft, which allows for easier cleaning and disinfecting, whether that entails wiping down the plastic or rebagging items. In some cases, air ambulances are identifying nonessential equipment for flights that can remain off the aircraft, thus reducing the volume of equipment potentially exposed and needing disinfecting. For the same reason, some are also taking less gear into the sending facility during an interfacility transfer.

Pilots who often helped the medical crews or accompanied them into medical facilities pre-COVID now remain with the aircraft and stay more than 6 feet from the crew and patient at all times. Additionally, a barrier now frequently remains between the pilot and crew continually during every flight, most often an NVG (night-vision goggles) curtain. The aircraft is also completely disinfected after each transport before it can return to service, with the medical crew disinfecting the cabin while the pilot disinfects the cockpit.

At bases and hospital ready rooms, pilots and staff are observing social distancing, often staying in their own offices. Some services also require pilots and flight crews to remain masked at all times. Others are initiating similar masking and social separation requirements for their maintenance staff  while also limiting the number of mechanics who may work on an aircraft at the same time and prohibiting nonessential people in the hangar.

Service operations themselves are also changing. “Prior to all this, we had strict liftoff times and monitored them closely, treating everything like a scene call,” Rohrbach says. “Now, we’re slowing it down for interfacility transports. We’re treating all flights as if everyone is a COVID patient. A lot goes into preparing the aircraft and crews to ensure we’re all safe. There’s also a longer out-of-service time at the end of flights while we thoroughly disinfect the aircraft.”

The lack of firm medical guidance in the early days of the pandemic created additional difficulties. Geisinger Medical Center owns and operates all of its nine aircraft, employing all staff, from pilots and mechanics to medical teams. When COVID began to reach its service area, the organization immediately banned air transports of known COVID patients.

“Around the beginning of March, when this was just taking off in our area, information about the virus and the recommended policies were changing daily, even hourly,” Splitt says. “We didn’t know a lot about how it was transmitted, and until we did and could safely protect our staff, we had to rely on ground transport.”

Geisinger slowly transitioned positive COVID patients to airlift as more information became available about the virus and how to safely transport those patients.

The Power of Teamwork

Across the board, air medical transport services are working together and with medical facilities to share information and best practices. Many hold daily calls to learn the latest information on the virus and recommendations for safe operations.

Colorado-based Global Medical Response (GMR) in January of this year officially combined all its air and ground operations, which on the helicopter side include Air Evac Lifeteam, Med-Trans Corp., REACH Air Medical Services, and Guardian Flight. COVID put the newly consolidated company to the test.

“I was really impressed with the level of communication that came from GMR to help all employees understand COVID and that we can safely transport people with this disease,” says GMR VP of Operations Joe Grygiel. Formerly with Air Evac Lifeteam, Grygiel found his new parent company’s coordinated communications effort a literal lifesaver.

“When everyone better understands, it helps ease anxiety and they can do their jobs better. COVID information is changing daily. What was said yesterday will change tomorrow,” says Grygiel. “With calls, a COVID-19 information website for employees, peer support, and even a chaplain line, GMR is making it possible for employees to focus on the job.

“The company was also able to put its weight behind efforts to get personal protective equipment for all of our teams, which is no small [achievement],” Grygiel adds. “They turned over quite a few rocks, but their buying power helped ensure our teams were protected.”

Metro Aviation, meanwhile, is focused entirely on aviation, employing 450 pilots and 250 mechanics across the country for medical customers. With no medical personnel on staff, the company has looked to its customers for support.

“We quickly assembled a medical director advisory committee to get feedback and direction on how to best protect our pilots, aircraft, and crew,” say Metro’s Morrow. “They did an excellent job of preparing us. And as things changed and more information became available, they kept us well informed to make decisions that are in the best interest of our people’s health and safety.”

Staffing Outlook

The COVID-19 health crisis has had one unexpected positive effect on the air ambulance industry: its staffing forecast. Helicopter operations in general have been losing pilots and mechanics to airlines over the past several years. The pandemic has hit the airlines hard, with a long, slow recovery anticipated. As commercial airplanes are parked around the world, some furloughed pilots and maintenance technicians are looking to return to the helicopter industry.

“We were losing pilots pretty fast to the airlines, and now those opportunities aren’t there,” says Grygiel. “This is where watching what happens to the commercial airline industry is going to be key to how our supply of qualified pilots and mechanics will be affected.”

As for medical flight crew positions, the shortage continues. Pre-COVID, facilities reported that their open positions attracted fewer applicants than in past years and, in some cases, very few qualified candidates.

“In the past, an open flight nurse or flight paramedic position would attract a long list of applicants,” says Cooper’s Rohrbach. “It’s hard to get a good pool, even before COVID, let alone people who meet the requirements. It’s getting harder and harder over the whole industry.

“However, there’s a lot of goodwill and sentiment with the public right now for health care,” he says. “I hope that will have a real effect. I hope a year from now, people will remember how valuable and important these professions are and how they put it all on the line for you. I hope more people will want to join these professions.”

Life after COVID

Air medical operators are staying up-to-date on the latest developments in this disease, pivoting as needed to maintain their ability to safely save lives. Longer term, the largest concern is an adequate PPE supply to meet the demand through the entire pandemic. And then there’s what happens after.
“You’ve got to figure all these people who’ve been cooped up and haven’t been able to do things are really going to get out and start [moving] when they can, even people who haven’t been that active in the past,” Morrow says. “I predict we’ll see an increase in heart attacks, strokes, trauma, and accidents as the states open up. We’re advising our people to stay staffed and prepared for that shift as COVID decreases.”