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Intensive Care: Medical Operators Adapt to COVID-19

In responding to COVID-19, four medical companies innovated to make their aviation operations safer and more secure.

Possibly the only sector more challenged by the pandemic than transportation has been healthcare. Air ambulances and doctors who fly endured even more turbulence, as caseloads sent flight demand plunging, then surging, with operators scrambling to protect patients and crews.

At a medical flight operation, everybody is an essential worker – from the pilots and schedulers to the maintenance technicians and flight paramedics. One year into the pandemic as vaccinations raise hopes for returning to normal, how have these operators adapted and performed their critical missions?

Outlasting the Volatility

When COVID-19 cases surged in mid-2020, air ambulances flew more than ever before. Sanford Health’s aeromedical King Air 200s and EC 145 helicopters are based across the Dakotas and Minnesota. In September, October and November, the hospital network’s fleet set three consecutive monthly records for flight hours.

“We were doing five COVID-19 transports a day, on average,” said Mike Christianson, senior executive director for aviation. “The intensity was incredible, but we never turned down a COVID patient.”

With such high flight volumes, maintenance phases occurred more rapidly. Flight crews and maintenance technicians worked hard to keep up, while continuing to focus on safety.

“We were doing five COVID-19 transports a day, on average. The intensity was incredible, but we never turned down a COVID patient.”

Mike Christianson Senior Executive Director for Aviation, Sanford Health

“We saw an uptick in our fatigue timeouts, but we have a deep bench of pilots,” said Christianson. “For us, that was an affirmation that our safety process worked.”

Mayo Clinic dealt with a similar surge in COVID-19 missions starting in July 2020. The hospital’s air ambulance fleet of EC 145s and a King Air 350 are based across Southern Minnesota and Northern Wisconsin. After nearly three months of very limited EMS flying during the initial days of the pandemic, demand for patient transport rebounded.

“We had volatility, yes. After the volume dropped off in the spring, July was a rapid return to EMS flying,” said Joel Kozlowski, director of aircraft operations for Mayo Clinic Ambulance Service.

As COVID-19 transports surged, the aviation team consulted with Mayo Clinic’s aerospace medicine and infectious disease departments, as well as the Centers for Disease Control (CDC), to make every flight as safe as possible. They also surveyed other Part 135 and Part 91 operators to understand how they were managing health risks.

“After the volume [of operations] dropped off in the spring, July was a rapid return to EMS flying.”

Joel Kozlowski Director of Aircraft Operations, Mayo Clinic Ambulance Service

Safety in Flight

Like Sanford and so many other operators, Mayo Clinic sanitized its aircraft regularly. Based on advice from Mayo Clinic disease experts, the maintenance technicians adopted a policy of letting the aircraft air out for 20 minutes after returning from a trip before performing their usual inspections.

Air ambulance flight and medical crews wore personal protective equipment (PPE) at all times. Neither Sanford nor Mayo ever were short of PPE. “The biggest challenge was the constantly changing guidance,” said Christianson.

“We started flying with surgical masks and N95 masks on every flight. But then we had a problem that pilots could not clearly communicate on the microphones with N95 masks.”

Bob Ringold Chief Pilot, Mayo Clinic Ambulance Service

The operators carefully followed expert guidance on gowning, face coverings and eye protection, but adapting those practices to the aviation environment was always a challenge.

“We started flying with surgical masks and N95 masks on every flight” said Mayo Clinic Chief Pilot Bob Ringold, “but then we had a problem that pilots could not clearly communicate on the microphones with N95 masks.

“We began flying COVID-19 patients in helicopters, but then the fixed-wing environment presented a unique set of challenges to think through,” added Ringold.

With a pressurized cabin, the King Air becomes a closed environment. During taxi operations, the external valves are closed. For added protection, Mayo Clinic closed the cockpit door and plans to soon add external HEPA filters to the cabin air vents.

Time to Prepare

Both Sanford Health and Mayo Clinic were well-prepared for the surge in EMS flying over the summer and fall because of actions they took during the springtime lull in operations.

With the downturn primarily affecting fixed-wing flying, Mayo Clinic reassigned two dual-qualified King Air pilots to the helicopters.

“With our training in-house, we were able to quickly reposition our fixed-wing pilots who were certified on the EC-145 and get them spun up on our rotor-wing procedures,” said Kozlowski.

For health precautions, Mayo Clinic had cancelled all trips to outside training facilities during 2020 and used the downtime to set up their own pilots as check airmen to complete all training in-house.

Mayo Clinic had the organization to bring check rides in-house, since the company had established a substantial training program in 2013 when it first received a Part 135 certificate. That certification involved writing “thousands of pages” of manuals.

Since then, the operator has digitized with Web Manuals, allowing for a more transparent way of structuring the content and sharing edits with each member of the aviation team, who can view those changes and make comments.

Mayo Clinic has evolved in several other ways, adding a Canadian operating permit and progressing to IS-BAO Stage 2. The operator also started participating in an FAA Aviation Safety Action Program, bringing their hazard-reporting function in-house.

Upgrades & Expansion

Sanford has evolved its flight operations as well. Sanford added a King Air 200 in Fargo, ND, primarily for physician outreach, and hired three pilots to expand that base. Sanford also purchased a new King Air 200GT to replace an old air ambulance. The new airplane has enabled Sanford to try out a new aeromedical interior, with safer seats and harnesses.

“We streamlined our avionics fleetwide. It’s made training a lot easier, and it feeds into our flight operations quality assurance program.”

Mike Christianson Senior Executive Director for Aviation, Sanford Health

“We also streamlined our avionics fleetwide,” said Christianson. “We had aircraft with Garmin 600, Collins Pro Line and other systems. We replaced all those with Garmin G1000s on every platform. It’s made training a lot easier, and it feeds into our FOQA [flight operations quality assurance] program.”

An outgrowth of its safety management system, Sanford’s FOQA program received FAA approval in late 2020.

Making Informed Changes

“It’s helped us make some informed changes,” continued Christianson. “We see what we’re doing well, where we can improve. You can view an animated re-creation of a flight with a deviation. The whole idea is learning and training,” concluded Christianson.

Patient Demand Stays Strong

Premier Bone & Joint Centers turned to telemedicine, but still is flying.

For more than 40 years, Premier Bone & Joint Centers has brought high-quality orthopedic care to small communities across Wyoming. From its Laramie, WY offices, the practice flies physicians to outpatient clinics on four King Air C90As.

“While our aircraft utilization is not back up to pre-pandemic levels, our patient demand last year was exceptionally strong,” said Cody Diekroeger, director of transportation and chief pilot.

Two longtime orthopedic surgeons retired from the practice in 2020, which partly explains the decline in hours. A new surgeon has been hired to join the practice in 2021, as orthopedic treatment returns to normal.

In the midst of the pandemic, Premier Bone & Joint’s physicians increased their use of telemedicine to reach patients at outlying clinics. They kept flying, too.

“We continue to operate a fleet of four King Airs with three full-time pilots,” said Diekroeger. “We’ve implemented COVID-19 safety measures, most noticeably flight crews and passengers wearing masks, as well as sanitizing the aircraft interiors.”

Aviation Still Key to Growth, Patient Care

Even as hospitals curbed meetings, Apogee Physicians continued to fly.

Managing more than 1,000 doctors nationwide, Apogee Physicians is the largest U.S. physician-owned hospitalist group. Dr. Michael Gregory founded the firm in 2002, and business airplanes have helped it expand to hospitals in 26 states.

“The bulk of our flying is to non-hub airports in small towns,” said Chief Pilot Greg West.

By 2020, Apogee was flying three jets a total of 800 hours per year. “Then COVID hit and everything stopped,” said Dr. Gregory. Throughout the year, hospitals limited the number of people and the duration of business meetings.

At the time, Apogee was operating two bases – one in Arizona and one in Idaho – and was planning to add a new model of light jet. Those reequipment plans are on hold, but Apogee’s airplanes still flew 225 hours in 2020, implementing regular COVID testing of flight staff, limiting hangar time, requiring mask wearing and sanitizing the aircraft regularly.

“Apogee is one of only a couple national health-care providers I know of that returned 100% of CARES Act funds,” said Dr. Gregory. “Despite the turmoil, we have maintained our flight department without any layoffs or furloughs. I’m still passionate about business aviation.”

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