Air Ambulance Patient Transport
With experienced staffs of helicopter pilots, critical care paramedics, emergency dispatchers, as well as aircraft maintenance engineers and administrative personnel, non-profit organizations operate specialized air ambulances across Canada, providing critical care and patient transportation to patients coast to coast to coast.

The largest of these non-profit air ambulance services is Ornge, which operates across Ontario. Comparable agencies include: Shock Trauma Air Rescue Society (STARS), which operates in Alberta, Saskatchewan, and Manitoba; Helijet in British Columbia; and LifeFlight in Nova Scotia, New Brunswick, and Prince Edward Island. These crisis response organizations are contracted by their respective provinces to provide rapid and specialized emergency care for critically ill and injured patients – particularly in the vast rural areas that compose much of Canada’s provinces.

As part of the country’s publicly-funded universal healthcare, the services provided by these aero-medical and land critical care transport organizations are covered under provincial plans.

Ornge: Aero-medical and Critical Care Capabilities
Performing more than 20,000 patient-related transports every year across Ontario, Ornge operates by land and air, day and night. From the dense urban canyons of the Greater Toronto Area to the near-tundra of the northern Hudson’s Bay coastline, it maintains the largest air ambulance and critical care land ambulance service in Canada, along with extensive communications and logistics capabilities through its Operations Control Centre (OCC) in Mississauga. It maintains land and air bases in Moosonee, Kenora, Sioux Lookout, Thunder Bay, Timmins, Sudbury, London, Toronto, Peterborough,  and Ottawa.

Officially a not-for-profit charitable organization, Ornge gets its name from the prominent colour of its air and land fleet vehicles (with the ‘a’ removed to allow for trademarking). The company serves 13.5 million residents across more than one million square kilometres – the combined size of France, Spain, and the Netherlands.

From its strategically-located bases, Ornge operates an impressive fleet of advanced air and land vehicles – 8 Pilatus Next Generation PC-12 fixed wing airplanes; 11 Leonardo AW139 helicopters; and 13 Crestline Commander land ambulances. Its pilots and paramedics proudly remark that the organization’s elegant yet tried-and-tested AW139 helicopters are essentially “emergency rooms in the air.”
With over 600 employees, Ornge provides aero-medical services for treatment within Ontario. Several factors are considered when determining whether a patient meets the Scope of Service criteria to warrant utilizing its critical care land ambulance program:

• Does the patient require administration of medications and/or blood products during transport that is beyond the scope of practice of a Primary Care Paramedic?
• Does the patient require specialized equipment or monitoring devices during transport (such as a ventilator, external pacemaker, multi-channel infusion pumps, hemodynamic or invasive monitoring, intra-aortic balloon bump, etc.)?
• Does the patient require a level of care during transport that either exceeds general nursing care or is beyond the scope of a Primary Care Paramedic?
• Is the patient at high risk of deteriorating during transport and may require specialized medical intervention?
• First Responders evaluate these conditions on a case-by-case basis to determine if the patient requires intervention by Ornge personnel.

Equipment & Services
The service’s critical care paramedics’ supplies and equipment (as well as experience) is said to rival some of the most advanced trauma care centres. A series of fully-stocked blue bags filled with monitoring equipment, surgical tools, and medications always sits poised on a stretcher beside the AW139 helicopter, ready for immediate dispatch at a moment’s notice. Air ambulance paramedics carry an extensive array of medications, sedatives, drills, monitoring devices, and whatever else is needed to stabilize patients for flights that can often last several hours over hundreds of kilometres.

So experienced and well equipped are these personnel, it is not an uncommon occurrence for in-house surgeons or doctors to request that they stay behind to help treat patients in hospitals and trauma centres. One Ornge paramedic reflected on some of the taskings that stood out most to him – responding to grisly, multi-casualty collisions on the Trans-Canada Highway network; being asked to instruct resident doctors on how to perform an intraosseous infusion (IO) through a patient’s bone; resuscitating a drowned child in Ontario’s far northern communities; and the delivering of about a dozen babies while mid-flight.

Beyond responding to emergency situations outside of urban centres, 90% of Ornge’s work involves transporting critically ill and injured patients between medical facilities. Alongside inter-facility patient transfers and on-scene responses by land or air, Ornge also provides “modified scene response” services, in which local land ambulance has already initiated transport of the patient(s), and which, pending agreement with a local physician, is then undertaken by Ornge. At times when there is no registered nurse (RN) or nurse practitioner present to attend to the patient(s), Ornge has qualified staff to provide “nursing station response” services.

Ornge is the primary provider of organ transport services by air in Ontario. Even if a non-acute patient does not meet the organization’s Scope of Service criteria, Ornge will nonetheless provide transport for organ recipients in the event that transport is over 240km (150 miles) away from the transplant facility or if the patient is in a geographic location where, due to time restrictions, may have no other means to arrive at the facility in time to have a successful procedure.

Its critical care land ambulance program currently operates within southern Ontario – specifically in the Greater Toronto Area, and the Ottawa and Peterborough regions. Its purpose is to relieve pressure from municipal land ambulance services, allowing them to focus on 911 emergency calls and to reduce the need for hospitals to provide escort staff for critical care patient transfers, as well as enabling Ornge to increase aero-medical availability for outlying rural and remote areas in which land ambulances may not be appropriate to meet acute patient requirements.

Innovation and R&D
Ornge invests significant resources in research and development for innovation in the field of aero-medical and land critical care patient transports. In leveraging insight from an extensive range of internal and external subject matter experts in patient care, education, information technology, aviation, and safety, the organization has built an exceptional track record of peer-reviewed publications, grants, and collaborations with likeminded stakeholders. Members of Ornge’s research groups serve on graduate and postgraduate boards across the province, lending their unique expertise to the fields of pre-hospital care, trauma care, and transport medicine. As well, the agency hosts a number of specialized internal and external training programmes, such as the Advanced Care Flight Paramedic course, the Aero-medical Theory Course, and extensive operational training workshops, including CPR, transportation of dangerous goods, underwater escape training, stretcher lifting, and the use of new medical equipment and technology.

Medical Documentation
Ornge’s Clinical Affairs department is an important link between the physicians, who provide medical support and direction, and the paramedics and RNs, who perform patient care during transport. This department is responsible for the management of all patient care documentation and collaborate with physicians to meet organizational objectives and administration of the Medical Advisory Committee (MAC). Ornge’s MAC consists of its own Medical Directors, all of whom are physicians (including the Chief of Staff), two patient and two paramedic representatives. Its mandate is to provide advice for, and supervision of, all aspects of care that fall under its scope.

Logistics, Triage & Travel
Employees remark that much of what they see – especially inside the helicopter while en route to emergency centres – is often beyond the norm of even municipal paramedic services. The added stressors, such as logistics and environmental factors (noise, vibration, and weather), and the typically lengthy travel times between remote Ontario communities, can make critical situations all the more urgent and precarious. Flexibility, adaptability, and resilience under stress are critical in order to effectively stabilize and treat patients under such strenuous conditions.

The OCC in Mississauga coordinates all communications and logistics related to Ornge’s medical air and land transport capabilities. The facility serves as a 24/7 hub that allocates fixed wing, rotary wing, and land ambulances to patients in need. Because Ornge is not publicly accessible via 911 emergency calls, requests come from local land ambulance services when the acute need arises.

Once a request has been issued, the OCC considers triage and resource reassignment decisions such as: patient condition, capabilities of the sending hospital, distance to the destination hospital, availability of local EMS resources, weather conditions, and the availability of its aircraft and ambulances. The Control Centre triages these requests much like any hospital would, which sometimes results in resources being redirected from one call to another at short-notice.

Frontline Responders
Once a list of pertinent information is acquired by the dispatcher (confirming the patient has met the Scope of Service criteria, receiving facility name and location, receiving physician’s name, patient’s provincial health card number, as well as contact information and time requirements for transport for a successful procedure) the pilots perform a weather check and, if safe to do so, the resources are dispatched. To ensure that decisions are made on the basis of safety considerations, rather than emotion, Ornge pilots are not privy to details of the medical situation. With many of its pilots coming from a military background, flying these air ambulances is often said to be the most prestigious and difficult position for which a fixed or rotary wing aviator can strive. The same can be said for the qualities sought for its critical care paramedics: flexibility, adaptability, and being resilient under pressure, all while making sure they can do their job effectively with limited information, resources, and time – typically a thousand feet or more above ground level.

In a service where the shifts are long and stressful, with sometimes-lengthy bouts of mundane inactivity, a supportive and understanding workplace among peers is key to reinforcing mental and emotional resilience.

During the scant downtime between taskings, the personnel at Ornge aero-medical transport facilities quietly maintain their equipment, perform routine administrative duties and avionics work, R&R in the base’s small lounge, or stay in shape with assorted cross-fit and cardio equipment that often sits poised, several feet away from the AW139 helicopters.

Then, come rain or shine, in temperatures 30-above or 30-below, when the phone from the OCC rings – everything stops, the supply-laden stretcher is loaded into the helicopter and, within minutes, the crew is once again en route to the next critical care scene.

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Casey Brunelle is an intelligence and strategic studies consultant with extensive experience in both the public and private sectors, specializing in counterterrorism, public safety, and geopolitics. A regular contributor to FrontLine magazine, he holds an MPhil in international relations from the University of Cambridge and an honours BSocSc in international development from the University of Ottawa.