What does a typical day at Ornge look like for you?
This can be variable, as I currently have a few roles under the Field Educator umbrella that make up about 30 to 50 per cent of my operational hours. The hours I am functioning as a critical care flight paramedic (CCP(F)) are typically on the AW139 and begin with standardized operational readiness tasks, followed by an AMRM (Aeromedical Resource Management) briefing session led by the senior captain at the base that shift, and includes flight medics, pilots, AMEs and management or admin staff. If a mission has not come in by that time, there is typically online education and other tasks to fill up the time; indeed, in the time of Covid, the amount of education is significant!
As our operation utilizes land and air assets, there are times when we may be switched to our on-site critical care land ambulance (CCLA) to facilitate responses when things like poor weather for flying occurs.
Over the past year, with the pandemic as a major focus, I have found myself on a wide variety of other initiatives, including working to help develop our Surge Response Team (SRT), education activities, and being deployed as a Task Force Team Leader (TFTL) to fly into remote, indigenous communities in northern Ontario to provide Covid-19 vaccinations. This has been a large scale multi-organizational collaboration, led by Ornge, and supported by many other organizations.
Your AMTC 2020 presentation focused on standardization of equipment onboard air ambulances; what originally prompted you to think standardization was necessary?
My involvement in the standardization process was certainly an evolutionary process. It began with a long-time desire to improve how we carried and stored our medications in the field. After various twists and turns, there was an opportunity to develop a system-wide equipment standardization plan. The need for standardization was rooted in a few areas of concern. As a large provincial service, we have staff who float between bases or could be reassigned to any vehicle at any point in time. With this in mind, we knew that we needed to create and maintain our medical gear exactly the same across the fleet, so our crews could be interoperable with any of our bases or vehicles. This had several end point objectives: first of all, it would reduce error risk, especially when merged with independent double checks and new medication administration technology. Secondly, it would reduce cognitive and psychomotor task load in high-stakes situations, reducing risk to our patients. It would also improve our state of readiness process and, by all of the aforementioned items, would ultimately reduce stress on our personnel.
How difficult was the process to achieve?
Any process to change current and long-held practices is definitively not easy. This is exponentially more difficult in a system that is as large and geographically distributed as Ornge. What we appreciated as we navigated this project was the fact that we needed our people to be well prepared for the changes on the horizon. I would like to think of it like ‘winning hearts and minds’. Our organization is rich with highly experienced and intelligent operators, and they appreciate hearing evidence-based reasons for just about everything we do – I am absolutely one of those people as well. So, over the period of 12 months or so in the later phases of the development, I made several visits to various bases around the province and spoke with as many front-line medics as I could to build some anticipation for the plan, and tried to clear up any assumptions or misinformation that may have been floating around.
While we avoided large-scale committees for this project and kept the team small, I can say that absolutely every comment or suggestion I heard from my colleagues went into my little notebook, and I made a point of telling them that I was putting it into the consideration list. Consequently, many of those ideas from around the system were incorporated into the structure of the standardized gear. Perhaps the moment that really made me smile was after the rollout, further changes had to go through our Paramedic Standards unit. I saw how really smart suggestions came forward and were implemented selectively after consideration and then changed systemically. Being outside of this loop and watching it work was a rewarding moment! Certainly, maintaining this standardization is an ongoing process, which we continue to strengthen through education and ‘practice-how-you-play’ approach in simulation settings.
What other cognitive offload tools should HEMS and SAR crews be using to mitigate the risk of task overload during missions?
I am an absolute believer in checklists and the practice of crew resource management (CRM) / AMRM in daily practice. Checklists and reference books continue to be humbling on a daily basis, and remind me of the fallibility of my own mind no matter my level of experience. It wasn’t so long ago that in professions such as paramedicine, we had this entrenched belief that to be competent, each practitioner needed to have perfect practice with no available references at hand, and be completely reliant on what they could access from memory. Dispelling this has taken time, but it is happening. Certainly, we need to have a strong knowledge base, and many things we can recall easily, but there are several high-risk / low-frequency situations in which the use of checklists and pre-mission deliberate practice that follows a standardized approach will mitigate risk significantly.
I also feel that our AMRM program has led me to learn to merge the collective knowledge and insight of any team I work with. I would suggest that this also reduces ones’ cognitive load in a significant way. In order to effectively do this in high-stakes, high-pressure environments, I think one needs the communication skills that develop through our AMRM education and daily deliberate use of the AMRM approach.
How has Covid affected your daily work at Ornge?
It would come as no surprise to your readers that Covid has changed our daily work in a significant way. While personal protective equipment became a mainstay of our practice during the SARS crisis 20 years ago, and transporting patients with droplet precautions is a common event for HEMS and critical care transport teams, the pandemic definitely saw us ramp up our personal and crew safety practices. From issuing half-mask respirators to our crews, developing reusable impervious gowns with Arc’teryx for use in cold environments, to performing scientific studies of aerosol dispersal in our various types of vehicles while in motion – to name just a few initiatives. The ubiquitous attitude within the organization has been that we can figure out how to address the challenges of ensuring the safety of our crews and staff no matter what scenario may present. Quite frankly, it has been amazing to witness.
Could you explain how the Covid SRT has been formed and deployed?
One day, in the early part of the pandemic, I was asked to go and look at one of our allied paramedic services multi-patient unit (MPU) and evaluate whether there was a possibility of using it in our Covid-19 response plans. As we contemplated this, we continued to envision all the possible situations in which we could be called upon to assist that could stretch our assets. With our Special Operations team recently organized, one of our highly qualified and experienced frontline flight medics, Pat Auger, was assigned to lead it.
Pat produced an Incident Management System (IMS) structure, and our team began to consider things like outbreaks in small fly-in-only communities or to areas where we did not have CCLAs permanently positioned, but there were local paramedic land ambulances. Pulling together equipment and supplies from within the system,
we built sets of standardized equipment so that we could deploy a scalable response of one to four critical care transport teams
we built sets of standardized equipment so that we could deploy a scalable response of one to four critical care transport teams to support any community in the province, above and beyond our standard assets.
Equipment was one thing given the global pressure on supplies, but none of it is of any use without the professional operators, and we were not disappointed when over 50 of our medics responded to a callout for volunteers who may need to go into unfamiliar operational situations.
The evolution led to stock of ready-state gear that could be loaded onto any vehicle from our HQ in Mississauga, and launched via any aircraft type. The teams would be able to convert virtually any ambulance in the province into a CCLA suitable for moving multiple patients from one site to another site for higher level of care. Patients who would require critical care management, including things like invasive line monitoring, multiple medication infusions and likely mechanical ventilation.
Thankfully, we have only had one deployment to date, which was not what we had specifically in mind during all of the planning, but the transport of 12 patients from an ICU just north of Toronto to a newly built facility. These patients were transported in a nine-hour span in collaboration with York Region Paramedic Services and the Ornge Surge Response Team. During this operation, no hospital staff or equipment was required for transport, which reduced the already significant workload on hospital staff.
Many of these patients required mechanical ventilation, high-flow nasal cannula and tracheostomy management, as well as invasive and central access lines, and multiple infusions, with several of the cases being Covid positive.
Mental health support for front-line workers has always been vital, but has really been thrown front and center during the pandemic. What support has Ornge put in place for its staff?
Ornge brought our Human Factor’s Specialist Tom Walker into our organization in 2013. Quite honestly, I personally feel like he is one of the most critical members of our organization. Since coming onboard, he has used his extensive knowledge, and has worked with tremendous dedication to build our collective resilience and our knowledge about mental health, both within our work world, and extending to our home life. After many hours of education sessions with Tom, we now have a group of trained peer supporters across the system, in various professional disciplines, available via an app to provide check-ins and other support for our colleagues. Entrenching the peer support model into our organization is notably a process, but the roots are in the soil, and I think we shall see a strong tree grow from them.
Government funding for air ambulance services is something that AirMed&Rescue has reported on in the past, and with Covid affecting economies the world over, do you foresee any major funding issues for Canadian air medical operators in the future?
My response to this comes as someone who isn’t directly involved in the matters of finance of operations, however, as a concerned member of the aeromedical community, it is not lost on me that the economic repercussions of the pandemic are likely to be very serious. Funding models have some degree of variability worldwide. This is no different in Canada. Fortunately, Ornge is funded wholly by the Ontario government. From where I am standing, our operation continues to have strong support.
For those systems not just in Canada, but around the world that use subscription or corporate funding to augment their service, I hope that where some sources of those kind of supports are no longer available, that other corporations and individuals will step in to take their place.
No matter what the funding model, I think that over the course of the pandemic, the flexibility of the paramedic profession to ramp up operations quickly and effectively, and enter roles that they hadn’t ever done before, will be noted. Consequently, as we move forward out of this pandemic, perhaps the aeromedical industry could see boosts in funding as our value-to-cost ratio leaps.
Ornge hosts the annual All Canada Aeromedical Transport Safety Conference every year; what’s the aim of the event, and do you plan to run a virtual version this year?
Ornge’s Aviation Safety team hosted the annual All Canada Aeromedical Transport Safety Conference in early March 2021. The aim of the event is to bring aeromedical operators together from across Canada to discuss industry trends and opportunities for improvement to continue to maintain the safest operation we can for our crews and patients.
Do you find industry engagement is more difficult without in-person conferences taking place?
I would actually say that the opposite is true. While I miss meeting my colleagues directly as much as in the past, I find that we are fortunate during this pandemic that technology is where it is at for communications.
I find that we are fortunate during this pandemic that technology is where it is at for communications
Video conferencing has made it easy to have safe, regular, and meaningful communications amongst our teams and within our organization. I would say that I feel more in touch with my profession and within my organization than ever before.
The AMTC presentation that my Chief Flight Paramedic Justin Smith and I did was very interesting to prepare and submit. Being able to be online and take questions with the people who viewed it at the time of the scheduled showing worked very well. I also had the chance to be on the other side of the video podium as an audience member, and felt that it was very engaging.
What do you love most about your job, and what do you find to be the most challenging aspect of it?
For the first part of the question, that list could go on for a long time, but I have two items at top of the list answers: the experience of being a small but integral part of a group who cares for the people who need us, and the inspiring people I get to work with – who also are often amongst the funniest people I know too.
For the second part, I firstly find the ubiquitous logistical challenges – be they small or large – to be the one of the most challenging parts of our work. Finding a landing site in a remote location, planning against duty day, weather, and other factors, to be able to get a time-sensitive patient to the care they need are some of the common situations that our crews face – and execute incredibly well I might add. For me, these types of challenges, and solving them, is highly rewarding