Introduction
Since COVID-19 has impacted the United States ambulance services have been in high demand and the air medical system has been increasingly overtaxed.1 Small community hospitals and clinics are constantly requesting flight crews to fly patients who they do not have space for, or cannot adequately care for due to the higher than normal patient volume.1,2 Due to the influx of patients statewide, these patients are then quickly shuffled to a larger hospital where they face even longer treatment times and faster discharges.1,2
This commentary will follow the work of a critical care flight paramedic in New Mexico during the COVID-19 pandemic.
Background
New Mexico has a population of 2.1 million residents and an area of 121,590 sq. miles (314,917 sq. km). It is serviced by 37 hospitals and 23 helicopters.
Most flight crews work a 24-hour rotating schedule with a single pilot configuration to accommodate a critical care flight nurse and a critical care flight paramedic. The crew fly an AS350B3E rotorcraft due to the altitude and performance needs, and cover a large area of Western New Mexico and Eastern Arizona, with a lot of the service area being Native American land. Particularly, covering a large area of Navajo Nation and other assorted reservations and pueblos. This area has been especially hard hit since the first New Mexico COVID-19 case originated in March 2020.
During an eight-week period in October and November, one base flew 121 patients in total. Many of these were patients from Navajo Nation, who we flew to other cities for higher levels of care however the healthcare system became increasingly overwhelmed, causing significant delays in access to care.
On Shift
A new crew arrive each day at 0530 for a 0600 start and complete a handover with the off going medical crew. During this handover crew debrief on the prior shift activities and sign over drug kits. The ongoing crew then conduct a daily aircraft and safety brief with the day pilot. Previously, pre COVID, once the startup procedures were finished, time was spent physically training, eating, napping (24 hours on shift requires this) however now with COVID things are different. Often within minutes of the handover, the loud alerting tone sounds and crews ready themselves for a new mission. The lift time target from dispatch remains less than ten minutes
There are two main mission profiles. The first type of mission is a scene call, where crews are dispatched directly to an emergency scene. This could be the side of the freeway, or someone’s backyard in response to a 911 (999) job. The second mission profile is a critical care interfacility transport (IFT). Oftentimes, these are transfer time-sensitive emergencies from local hospitals and clinics to higher levels of care. Regardless of the profile the sorties typically take three to five hours in length with roughly up to four calls per 24-hour shift.
But since March of 2020, nothing has been typical due to the COVID-19 pandemic. From addition PPE and decontamination to patient care issues, clinicians have been constantly tested.
A common shift during COVID 19 may look something like this:
0530 – Arrive on base to conduct handover.
0600 – Commencement of shift – flight checks and kit checks complete
0603 – Dispatched Inter-Facility Transfer (IFT) (70, male, respiratory failure, 25 minutes to scene, full PPE required and a full aircraft decontamination following case completion)
1206 – Dispatched Scene (56, female, shortness of breath and chest pain, 20 minutes to scene, full PPE required and a full aircraft decontamination following case completion)
1758 – Dispatched Scene (19, male, multisystem trauma from MVA, 10 minutes to scene, full PPE required and a full aircraft decontamination following case completion))
0130 – Dispatched Inter-Facility Transfer (IFT) (35, female, respiratory failure, 30 minutes to scene, full PPE required and a full aircraft decontamination following case completion)
Problems with PPE in Flight
As healthcare providers working with infectious disease patients, crews must first protect themselves with proper safety gear. Summertime temperatures in New Mexico can get as high as 110º F (43.3º C). This can significantly impact crew’s ability to operate in full PPE and stay cool and hydrated. Additionally, the face masks or shields hinder air crew’s usage of the inflight intercom system. The additional equipment is cumbersome, and the aircraft interior is limited by space adding to the stressors of flight work.
Lengthy Decontamination of Aircraft
Following every sortie the aircraft must be thoroughly decontaminate regardless of patient symptoms. This is to protect the crew and the patients. Every piece of equipment, surface and handle must be thoroughly cleaned prior to reset. During the winter months where New Mexico dops below freezing the decontamination is complicated from surfaces freezing. This delays the crew readiness for the next sortie.
Prioritizing Patient Care and Flight Crew Safety
COVID-19 is an evolving pandemic which has created much confusion in best care. It has challenged every ambulance service in the country to maintain or understand industry best practice. Aerosol generating procedures such as BiPAP or ETT intubation place the crews and flight team at much higher risk. Research has shown that intubating COVID-19 patients increases mortality rates. While placing patients on non-invasive positive pressure ventilation (BiPAP) can place flight crews at a higher risk of exposure, it has been proven to lead to better patient outcomes.3.
Conclusion
With many flight crews around the country experiencing similar situations this commentary was to record the current situation of a flight crew in New Mexico during COVID 19.
References
- Cornelius B, Cornelius A, Crisafi L, Collins C, McCarthy S, Foster C et al. Mass Air Medical Repatriation of Coronavirus Disease 2019 Patients. Air Medical Journal. 2020;39(4):251-256.
- Abelson R. Covid Overload: U.S. Hospitals Are Running Out of Beds for Patients. New York Times [Internet]. 2021 [cited 7 February 2021];. Available from: https://www.nytimes.com/2020/11/27/health/covid-hospitals-overload.html
- Mukhtar A, Lotfy A, Hasanin A, El-Hefnawy I, El Adawy A. Outcome of non-invasive ventilation in COVID-19 critically ill patients: A Retrospective observational Study. Anaesthesia Critical Care & Pain Medicine. 2020;39(5):579-580.
