It feels redundant to state that the Covid-19 pandemic has posed considerable challenges to aeromedical services around the world. But it is worth emphasizing; these services, which are often labeled as no-fail operations, have had to adapt their techniques and procedures to ensure crews are as safe as possible during the heightened pressures of the pandemic. These efforts have evolved during the course of the pandemic and been tempered as crews have become vaccinated, but being vaccinated doesn’t mean one can’t contract Covid. As the risk of contracting still exists, aeromedical providers continue to work to ensure safety for their crews. However, every provider takes their own nuanced approach to the problem.

How the Canadian Air Force coped during the early days of the pandemic

The Royal Canadian Air Force (RCAF) provides military air resources in response to SAR taskings. On the rotary wing side, the CH-149 Cormorant and CH-146 Griffon helicopters are the primary aircraft used to respond to SAR. On the fixed-wing side, aircraft like the CC-115 Buffalo and CC-130 Hercules offer dedicated SAR personnel and specialized equipment such as air-droppable survival kits, including life rafts and shelters. During the early days of the pandemic lockdown, only essential personnel would inhabit squadron spaces, while RCAF SAR crews would quarantine and undergo regular testing to maintain crew safety and responsiveness.

Colonel Dany Poitras, who at the time of speaking was Commander of 19 Wing, and the Chair of the Search and Rescue Capability Advisory Group, spoke to AirMed&Rescue about crew safety: “At the squadron level, we adhere to all the protective health measures which are in place which includes masks, which we’re all now familiar with. If anyone shows any signs of symptoms, they are not allowed to report to work. On the flying side, it’s much the same where crews are expected to wear masks unless there is a flight safety issue. For example, you could be flying at night and the mask makes your visor or night vision goggles fog up, so it’s understood that the mask can be removed for critical phases of flight.”

Poitras continued: “Because we deal with the unknown in SAR missions, we work with the assumption that others are Covid positive, particularly if they are symptomatic. We have a strong protocol of decontamination and cleaning the aircraft and equipment after every mission, and this includes having washing machines available so all crew uniforms can be sanitized. What we’ve noticed in the RCAF is there is very little transmission in the workplace, which tells me the procedures that we have in place are working.”

What Colonel Poitras spoke of is, in one way or another, what most aeromedical operators have implemented in their effort to keep crews safe during the pandemic.

The proper and effective use of PPE

In the US, Air Methods is an industry leader and expert in Patient Critical Care Logistics, and has been dedicated to emergency air medical transport. Speaking to AirMed&Rescue about crew safety during the pandemic, Joseph Resnik, Senior Vice President of Safety at Air Methods, stated: “What we’ve primarily been doing for crew safety is related to commercially available personal protective equipment (PPE) and process procedures. Whether it be masks, gowns, gloves, face shields or respirators, we provided all of it, and we mandated the use of those for any transport, not just suspected Covid transports. Many forget that wearing PPE can lead to dehydration, particularly in a lot of the hot areas we work in, so we always recommend that our crews stay hydrated and cool after they finish transporting patients.

“We require our crews to decontaminate and follow standard operating procedures for the containment and disposal of used PPE and regulated medical waste. They might have to change their flight suits, and they always wipe down their helmets so they’re ready to go. We also implemented cleaning procedures for aircraft following CDC [Centers for Disease Control and Prevention] guidance, which means there is an antiseptic wipe down of every aircraft after a transport, including aircraft vents. All of that led to longer turn times between transports, but we felt it was more important to be safe than to rush that process.”

Effectively managing the spread of Covid on aircraft

However, according to Resnik, there is little that can be done to install barriers in aircraft, particularly as such devices often need certification for airworthiness.

“We did look at barriers as a potential, but we did not see that as practical for a few reasons, including size and weight, and the fact that many barriers are not certified to be in an aircraft to begin with. There also really isn’t anything we could install in the way of isolation for the cockpit because in a lot of the helicopters we fly – the Bell 407 and Airbus EC135 and EC145 – in many cases the patient’s legs extend into the cockpit area where a copilot would have been. We also recognize that most of the patients we carry are intubated, so if you maintain appropriate filtration devices such as HME/HEPA microbial filters any time ventilation is provided, then that should be sufficient as a barrier, and we’ve proved that to be the case.”

One of the main pieces of equipment that Air Methods acquired for its pilots and clinicians was the Gentex Low Profile Particulate Respirator (LPPR). The LPPR is a half-mask respirator which, according to Gentex, offers 99.97 per cent filtration efficiency against a wide range of oil and non-oil based particulate contaminants encountered by aircrew during training and in operational environments. The LPPR has front mounted inhalation valves and two exhalation valves for easier breathing, can be configured for all major aircraft intercom systems and portable radios, and also seamlessly integrates with Night Vision Goggles and other eye protection products.

Resnik continued: “We knew that Gentex was designing a mask for the US Army and the Coast Guard to mitigate inhaling gunfire fumes and particulates, so we received the benefit of that design. One of the key reasons we went with the Gentex mask is it has a microphone incorporated into the respirator with a replaceable filter. The filters we use are equivalent to a National Institute for Occupational Safety and Health P100 filtration standard.

“In addition to the safety aspect, the LPPR improves communication clarity by reducing the noise associated with a standard boom microphone. Pilots and clinicians can wear N95 masks if needed, but it makes communication a little more difficult when they’re used along with a standard helmet and microphone combination.”

Procedure and protocol to minimize coronavirus spread

Air Methods also instituted a procedural protocol at the completion of each transport, where crews leave the doors of the aircraft open for a minimum of 10 minutes to allow for air exchanges to remove potentially infectious particles. After ‘doors open’ air exchange has occurred, decontamination procedures would begin, with the aircraft doors remaining open for an additional 10 minutes. Disinfection is performed using SaniZide (Sanizide-Plus or SaniZide Pro 1) or an equivalent Environmental Protection Agency-approved germicidal. In addition, MedeSol, a patented antimicrobial disinfectant, is used on a weekly basis for additional protection to reduce decontamination time, if possible.

“Of the over 8,000 Covid transports that we have done since the beginning of the pandemic in March 2020, we have had only three of our teammates actually contract Covid. We can’t say for 100 per cent certain that Covid was transmitted during the transport, but in each case we believe it was a failure of PPE that was most likely the cause,” said Resnik. “Aside from those occurrences, we’ve been quite successful in keeping our teammates safe during the pandemic, and we believe it really boils down to the basics of adhering to PPE and sound procedures. None of that could have been done without our supply chain keeping on top of things and securing the appropriate equipment.”

Midlands Air Ambulance and the UK perspective

Midlands Air Ambulance serves the largest air ambulance region in the UK, representing a population in excess of six million. The charity responds to an average of 4,500 missions each year, with over 2,000 of the deployments being air missions.

Ian Jones, Air Operations Manager for Midlands Air Ambulance Charity, highlighted the precautions made to keep crews safe during the pandemic: “As we are treating patients who are in a critical condition following a traumatic incident or medical emergency, and may be presenting symptoms of Covid, we had to act swiftly to ensure our service remained operational, as well as looking after the safety of the crew and patients.”

As well as the aircraft, Midlands Air Ambulance has taken steps to mitigate the risks to its crew and patients. As key workers, the clinical team, pilots and charity staff were among the first to receive the Covid-19 vaccine, a critical level of protection in the fight against the pandemic.

“Our aviation partner, Babcock, supported Midlands Air Ambulance Charity by adopting new PPE standards for crews while transporting patients. This included the implementation of a barrier system that separates the pilot crew in the front from the medics in the back,” said Jones. “The pilots are a critical part of our team and this helps to give an additional level of assurance for them to ensure they are protected from airborne particles.”

UK and Spain collaboration to combat Covid

According to Babcock, its engineers across the UK and Spain collaborated to design and develop the on-board barrier which effectively separates the medical teams from the flight crews on all their international fleet of air ambulance helicopters. The barrier has been customized by teams in Staverton, Gloucestershire, and following rapid prototyping by Babcock in Devonport, the system is fully approved for use on EC135, H145, and AW109 air ambulance helicopters.

Babcock Engineering Project Manager, Steve Hughes, said: “Projects like these would normally take several months but, using new guidance from the European Union Aviation Safety Agency and the UK Civil Aviation Authority, we have accelerated this process to just a few weeks. It’s a fantastic achievement by everyone involved, being able to offer this capability will make a huge difference. I think some of the lessons learnt here will change how we work forever.”

Much of the PPE used by Midlands Air Ambulance has been supplied by health partners, West Midlands Ambulance Service University NHS Foundation Trust, while pilots were provided with appropriate PPE on-board by Babcock to ensure they have adequate protection while flying helicopter emergency medical service missions. Jones continued: “Our level 2 PPE is worn when treating patients who are not presenting with Covid symptoms. This consists of surgical masks, gloves and an apron. Over time, we believed it was more appropriate to decrease the thickness of the plastic aprons. Initially, our level 3 PPE included powered respirator hoods with Tyvek suits.

The challenge for the aircrew was they could not wear the hood under a flight helmet, and they are required to wear a helmet for helicopter emergency medical service missions. As the pandemic progressed, we were not able to fly patients who had received aerosol generating procedures [AGPs], such as intubation and airway suction. The solution we found is the GVS Elipse FFP3 half face mask. We have had 100 per cent fit test success without compromise when wearing a flight helmet. Another consideration we had was the impact of wearing the mask on the aircraft and intercom effectiveness. The mask exhaust valve is on the front of the mask and the intercom microphones on the helmets sit just to the side of the mouth.

“So, with the mask on, it was difficult to hear on the intercom and the radio. Our solution was to acquire additional microphone booms for our Alpha Eagle flight helmets and bring the mic forward to be positioned directly in front of that exhaust valve. With a GVS Elipse mask, eye protection and Tyvek suits, we can transfer patients with AGPs ongoing in the aircraft. If we deem it more appropriate for the patient to be conveyed by road, the crew will use the 3M Versaflo powered respirator hoods and a Tyvek suit for AGPs.”

As with other operators, Midlands Air Ambulance also adheres to a rigorous cleaning and disinfecting protocol.

“It is always important to clean the interior of the helicopter between missions, and now where a suspected or potential Covid patient has been onboard, we undertake a deep clean with Dizmoson, which is something we now do once a week as standard on each aircraft. This was thanks to Airbus finding a suitable cleaning agent that would not corrode vital parts of our helicopters. Plus, we use Clinell wipes and chlorine to clean the medical equipment,” said Jones. “Together, with our health and aviation partners, and via sharing best practices across the air ambulance community, we are providing the right protection for our crews and those we treat, no matter what the situation.”