Ornge, an air medical service operated by the Canadian province of Ontario, traces its roots back to 1977, when its forebear the Ontario Air Ambulance Service was established.

Initially flying a single helicopter named ‘Bandage One’, the service, based out of Toronto’s Buttonville Airport and operated by the province’s Ministry of Health, expanded substantially over the next few years. In 1981, it opened new bases in Sioux Lookout, Thunder Bay, Timmins, and Sudbury, with a further four opening in 1999 in Kenora, Moosonee, Ottawa, and London.

In 2005, the Ontario Air Ambulance Service was folded into a new service that brought together all elements of Ontario’s air ambulance and critical care transport system into one organization for the first time. The organization’s name: Ornge (pronounced ‘orange’).

Previously reliant on third-party operators, Ornge began the process of bringing its air operations in-house from 2009, while also acquiring what would become its current fleet of aircraft.

A mixed fleet of aircraft

In the present day, the service operates an expansive mixed fleet of 12 Leonardo AW139 helicopters and eight Pilatus PC-12 NG fixed-wing aircraft, as well as a number of ground-based critical care vehicles.

“Our helicopters are based in Toronto, London, Sudbury, Ottawa, Thunder Bay, Kenora, and Moosonee, while the airplanes are based in Timmins, Thunder Bay, and Sioux Lookout,” explained Joshua McNamara, Ornge’s Communications Adviser.

Across the entire province of Ontario, Ornge typically completes approximately 21,000 patient-related transports each year using helicopters, airplanes, and critical care land ambulances

Of these, he explained, generally four of each are either receiving maintenance or being retained as backup aircraft at any one given time. Maintenance, he added, “is performed in-house by a dedicated team of aircraft maintenance engineers”.

Serving Ontario

Across the entire province of Ontario, Ornge typically completes approximately 21,000 patient-related transports each year using helicopters, airplanes, and critical care land ambulances, said McNamara – in 2023, the exact number of patients was 21,450, up 5% compared with the previous year.

The services’ operations are dominated by interfacility transfers, he explained, with approximately 94% of missions falling into that category. The remaining 6% “were transported from the scene of injury, or were modified scene calls”.

“Most of our emergent calls involve moving a critically ill patient from a small community hospital to a tertiary care facility where they can receive a higher level of care,” McNamara noted. However, when Ornge does respond to emergencies, the exact incidents can be diverse, including “vehicular crashes, traumatic falls or events, and critical illness or infectious disease”.

Among other things, the province’s “vast geography and regionally dispersed populations” are both a challenge for Ornge and a key reason for the service’s creation. Ontario encompasses an area of around 1 million km² – roughly equivalent to the combined size of France, Spain, and the Netherlands, but with a much lower population density of just 14 people per km².

the province’s vast geography and regionally dispersed populations are both a challenge for Ornge and a key reason for the service’s creation

“Patient populations in northern Ontario include remote, ‘fly-in only’ Indigenous communities, which often lack the resources like diagnostic testing, blood products, and ambulances to treat patients,” said McNamara. “Additionally, many of the small community airports in northern Ontario lack critical infrastructure, such as weather reporting and de-icing, to be able to appropriately respond during weather events.”

Crew and training

Ornge recruits crewmembers from around the world, said McNamara: “We are frequently in search of aviators and medical professionals interested in making a difference in the moments that matter most to our communities.

“We currently recruit internationally trained critical care paramedics from the UK, South Africa, the Caribbean, Australia, and New Zealand,” he added.

Ornge paramedics receive national leading continuing professional development that includes physician- and paramedic-led training, including just-in-time training at base, as well as regular in-hospital clinical rotations

Pilots receive a range of training, McNamara continued. New pilots for both fixed-wing and rotorcraft participate in “two weeks of intensive in-class learning and self-study prior to training at FlightSafety International, where they learn to fly the PC-12 NG in a full-motion flight simulator”.

Simulator training includes emergency procedures for a range of incidents, including blizzards, thunderstorms, and zero-visibility fog, he added.

Meanwhile, said McNamara, Ornge’s critical care paramedics receive similarly broad training, in the use of medical equipment, procedures, and pharmacology.

“With the support and guidance of the Ornge Medical Advisory Committee, our flight paramedics have immediate access to physicians with specialties ranging from anesthesia to neonatology,” he explained. “Ornge paramedics receive national leading continuing professional development that includes physician- and paramedic-led training, including just-in-time training at base, as well as regular in-hospital clinical rotations.

“The critical care paramedic level of care is the highest level of care in paramedicine. Ornge is one of only a handful of employers in Canada that offer training and service [to this level],” said McNamara. “We believe in going above and beyond Transport Canada requirements in our flight training because our number one priority is the safety of our crews and the patients of Ontario.”

McNamara also mentioned that, alongside its training for permanent crew, the organization runs a fellowship program for physicians interested in joining Ornge for a short period to gain more experience in the field of pre-hospital air ambulance operations.

Growing for the future

Looking to the future, McNamara said that Ornge is working to face rising demand head-on – demand driven, in part, by Ontario’s growing and aging population, which currently sits at around 15 million people, but is projected to increase by 43.6% over the next quarter century.

From 2026, Ornge will begin phasing out its PC-12s in favor of a more modern fixed-wing fleet, McNamara reported. The service is also looking to station “additional fixed-wing aircraft … in Sudbury, to serve patients in the northeastern region”.

Furthermore, Ornge is looking to expand its critical care land ambulance fleet to offer more interfacility transfers “within urban centers and along highway corridors”.

Ornge continues to explore new technology and training, such as enhanced power-loading stretcher systems and specialized equipment for special patient populations

The resulting additional capacity, McNamara explained, “will ensure the right vehicle is available for the right patient in their time of need”.

Beyond this, Ornge continues to explore new technology and training, such as “enhanced power-loading stretcher systems [and] specialized equipment for special patient populations – bariatric, extracorporeal membrane oxygenation (ECMO), special pathogens, etc.”