key: cord-0775489-3rv17inb
authors: Osborn, Lesley; Meyer, David; Dahm, Paul; Ferguson, Brandy; Cabrera, Rodolfo; Sanger, Damon; Mock, Michael; Herrera, Tony; Mader, Shelby; Ostrosky‐Zeichner, Luis
title: Integration of aeromedicine in the response to the COVID‐19 pandemic
date: 2020-06-04
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12117
sha: 1c71e7784b629175568f7760dfaddcac569a5283
doc_id: 775489
cord_uid: 3rv17inb

There is limited guidance on the use of helicopter medical personnel to facilitate care of critically ill COVID‐19 patients. This manuscript describes the emergence of this novel virus, its mode of transmission, and the potential impacts on patient care in the unique environment of rotor wing aircraft. It details the development of clinical and operational guidelines for flight crew members. This allows other out‐of‐hospital clinicians to utilize our framework to augment or supplement their own for the current response effort to COVID‐19. It further serves as a road map for future response to the care of high consequence infectious disease patients.

virus of mammalian origin, is spread via respiratory droplets in a manner similar to what was experienced in the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS).

SARS-CoV-2 is highly infectious and can cause a severe pulmonary illness with features similar to acute respiratory distress syndrome. 3 The most common symptoms seen early in the spread of this virus in Wuhan, China, were fever, cough, and shortness of breath, with higher mortality rates seen in patients older than 60 years and in those with common medical comorbidities like diabetes, hypertension, and coronary artery disease. 3 Though COVID-19 resembles SARS and MERS, the case fatality rate appears to be significantly lower. 4 patients. 6 

Ground EMS ambulances are uniquely equipped to manage droplet and airborne diseases. They do so often in caring for patients with influenza (droplet transmission) and tuberculosis (airborne transmission). Isolation of the patient compartment from the passenger compartment and filtration of the air are possible in ground transport vehicles, which creates a safer environment for the healthcare workers who work within them.

In contrast, a helicopter air ambulance is unable to isolate the pilot compartment from the patient compartment -the cabin is typically a single, shared environment between the pilot and medical personnel. 7 This presents a unique challenge: protection of both the pilot and the medical flight crew. Helicopter utilization in the transport of HCIDs is further complicated by the size of the aircraft, as it is uniformly accepted that patient placement should be away from the pilot whenever possible, which makes this guideline more feasible for larger air frames in which the patient compartment is in the aft. 8 Of course, certain fixed wing aircraft could be considered, as fixed wing commercial aircraft have the unique ability to limit the recirculation of air. 8 However, only a minority of aeromedical agencies in the U.S. utilize fixed-wing aircraft for patient care, typically for long-distance transports.

Current literature on the use of rotor wing aircraft in response to HCID In fact, the most common reported reason for flight refusal for HCIDs was tuberculosis. 14 In response to the current COVID-19 pandemic, the involvement of helicopters and flight medical teams has been sporadic. In the midst of rapid expansion of this virus in Italy, the Italian military helicopters (HH-101A) were integrated into their national plan on March 6, 2020.

These particular aircraft are typically utilized for specialized transports and are staffed by crews who have extensive biocontainment training. 15 In the United States, both fixed wing and rotor wing aircraft are being utilized in response to COVID-19. However, the response lacks uniformity, and there remains uncertainty about the safety of flight crews in close proximity to these HCID patients.

Identification and inclusion of key stakeholders was the next critical step in development of these guidelines. The following individuals were identified as vital in the development of a successful strategy to incorporate the helicopter air ambulance program into the system response to COVID-19: flight program director, medical director, chief flight nurse, chief pilot, safety officer, chief of dispatch, chief of helicopter maintenance, the disaster management physician for the hospital system, the lead physician for infectious diseases for the hospital 

CDC guidance for public-safety answering points and emergency medical dispatch centers includes recommendations that dispatchers should modify caller screening questions to include COVID-19 questions and notify EMS clinicians as early as possible prior to patient contact. 7 and safely execute the mission. As crew safety remains the primary concern for any mission, the pilot is afforded the opportunity to accept or reject the mission based on weather conditions prior to the unblinding of the medical crew.

Dispatch also plays an integral role in communicating with the receiving facility and in coordinating essential hospital personnel and equipment. This allows the receiving medical team adequate time to don personal protective equipment (PPE) and prepare the isolation room for the incoming COVID-19 patient, as well as prepare the necessary equipment and personnel to expedite the patient hand off safely and allow the flight crew to begin the tedious, but essential decontamination procedures.

Heightened awareness of air medical crews is critical to preventing further spread of the virus to themselves and to future patients involved in helicopter transport in the same aircraft. 17 

Life Flight employs a flight nurse, flight paramedic, and pilot staffing model. Additional clinical crewmembers are typically included for specialized patient care (eg, pediatric critical care and ECMO). However, this specialized staffing model was updated on the COVID-19 aircraft (discussed in detail below). The ride-along program was halted in response to regional and state guidance to limit contact with COVID-19 patients by non-essential personnel. While the pediatric critical care transport team would continue to transport non-COVID-19 patients in the aircraft, adult medical crews were assigned to transport pediatric COVID-19 and PUI patients. An exception to the staffing restrictions was made for perfusionists in the event of a COVID-19 ECMO transport.

Revisions to existing patient care protocols, specifically regarding airway management, were necessary to limit the number of clinical providers involved in invasive airway maneuvers, as this had been shown to be associated with increased risk of transmission of HCIDs to healthcare workers during the SARS epidemic. 20 The following air- Adjustments were also made to the approach in caring for cardiac patients in flight. Our standard guidelines for ST segment elevation myocardial infarction (STEMI) patients utilize tenecteplase administered in-flight for systemic thrombolysis, typically followed by immediate transport to the catheterization suite upon arrival at the facility.

However, due to the heightened concern for STEMI patients presenting with concomitant COVID-19, the operational guidelines were updated to include transport of these patients to the emergency department for COVID-19 screening and potential rapid testing prior to decision to go to the cardiac catheterization suite.

Unique to air ambulances, the crew consists of personnel (pilots) that are assigned solely to the operation of the aircraft. The addition of a pilot creates further opportunity to improve operational guidelines in response to HCIDs. Multiple challenges were identified that were specifically related to the pilot and the aircraft operations.

A single EC-145 aircraft of our 5-base, 6-helicopter fleet was designated as the COVID-19 aircraft. The aircraft chosen was the one assigned to central base, housed atop the level 1 trauma center. Typically, this aircraft is staffed twelve hours daily to perform specialty flights (ECMO, balloon pump, LVAD, Impella, neonate/pediatric, obstetrics, etc). However, with the expected increase in COVID-19 flights, this aircraft was assigned to cover these patients 24 hours a day, 7 days a week in order to limit the number of aircraft that would need downtime for decontamination and to limit the number of crewmembers exposed to this virus. Crew members were selected on a volunteer basis. The COVID-19 aircraft became operational on April 1, 2020.

As our rotor wing aircraft have an open compartment between the patient care area and the cockpit, pilots were fitted with N-95 respirators to provide appropriate personal protection in the event that a patient in transport required aerosolizing procedures. 7 These are worn with their standard flight suit and helmet uniform. The aircraft was stocked with emergency PPE kits to allow the pilots to don further protection (gown and gloves) if necessary. In order to decrease the potential for breach in PPE and exposure to COVID-19, pilots were restricted from assisting with patient loading and off-loading, unless absolutely necessary (due to patient weight, accessory equipment, stretcher failure, etc). This restriction was designed to prevent contamination of the instrument panels and flight controls. All COVID-19 missions require the blackout curtains to be drawn to add a final layer of protection for the pilot and cockpit. to these facilities, to prevent safety mishaps.

Medical helicopters, like ground ambulances, can be difficult to decontaminate. 21 The decontamination procedure consists of 3 main steps:

1. 

On April 2, 2020, we completed our first COVID-19-positive patient transport. At the time of dispatch for this mission, the patient was being cared for in the intensive care unit of a community hospital.

The patient had profound hypoxemia and shock requiring ventilatory and vasopressor support as well as prone positioning. The flight team, in conjunction with the perfusion team, assisted with cannulation for ECMO and then transported the patient to the quaternary care center for admission to the designated COVID-19 Intensive Care Unit. There were no reported PPE breaches and the crew has since completed their 14-day self-monitoring program that involves fever and symptom analysis twice daily. To date, we have successfully cared for 6 COVID-19 patients, all of whom required invasive ventilatory support. In total, 8 flight crew members have been involved in HCID transports, and none have warranted testing or quarantine based on symptoms and exposure risk per CDC guidance. 24 

At the time of writing this manuscript, all 50 states have reported cases of the virus. ≈1,062,446 COVID-19 cases have been reported nationally with 62,406 fatalities (816 in Texas). 25, 26 In developing these guidelines, the CDC guidance from the SARS response was utilized heavily, as was feedback from our colleagues in the aeromedical community. Early identification of potential hurdles and the importance of integrating hospital leadership and subspecialty partners were critical to the completion of these guidelines. 27 Flexibility and maintaining a working document are important, as this pandemic will continue to produce clinical data that will further influence the care of this unique patient population and improve aeromedical response and integration into future medical disasters.

The authors would like to sincerely thank the flight nurses, flight paramedics, pilots, dispatchers, and maintenance personnel, who have continued to show their unwavering commitment to our community through compassionate, professional care to patients during the COVID-19 response.

Lesley Osborn MD https://orcid.org/0000-0003-3536-5694

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