Challenging times require clarity in decision-making (April 2020) The way we function as a society has changed profoundly over the past month or so and we are all trying to understand the changing landscape we now live and work in. Some things, however, remain as clear as ever; during times of real challenges (no matter what area of work you are in) you need robust processes in place, enabling good decision-making and an honest and transparent approach. In this blog we wanted to share some of the operational challenges Devon Air Ambulance (DAA) now faces and the reasons that have led us to temporarily stand down the aircraft and respond to patients using our Critical Care Cars. It’s important firstly to mention the context of our decision-making. As a Helicopter Emergency Medical Service (HEMS) operator we need to work within often complex EU aviation regulations, which are controlled in the UK by the Civil Aviation Authority (CAA). Whilst some HEMS operators contract commercial companies to deliver their aviation function, DAA is an EASA/UK CAA approved Air Operator and employ our own pilots and aviation staff. Additionally, it is now a year since DAA became independently registered with the Care Quality Commission (more on that achievement soon), which means we also directly employ our team of paramedics and employ or contract our doctors. These factors are important because it means, within the bounds of strict aviation rules, DAA is wholly responsible for the decision-making process involved with how we deliver the service and ensure the safety of patients, the public and our staff. It follows, that at every stage in this process we need to focus on accurate information and facts to enable us to fully evaluate the risks and make the informed decisions for our patients, our staff and the wider healthcare community. Let’s have a quick recap of what we know about Coronavirus We know that this virus is very easily transmitted through both airborne droplets and physical contact and it is more infectious than normal flu (according to World Health Organisation figures in March, each Coronavirus patient will infect a further 2 to 2.5 people, whereas around 1.3 people will become infected from a patient with normal flu). People respond to Coronavirus infection on a sliding scale of severity; from those with no perceived illness, through to those who suffer unpleasant flu-like symptoms to those (particularly people with underlying health conditions) who are hospitalised and require intensive care support and ventilation. The growing number of people globally who have died as a result of Coronavirus is testament to the severity of this pandemic. Protecting our patients, our people and the healthcare community Once we had drawn on various sources to understand the issues involved with delivering healthcare within Coronavirus environment, we applied that knowledge to our emergency pre-hospital setting based on the deployment and use of HEMS helicopters. The following key elements were considered as part of our risk assessment process.... When helping potential Coronavirus patients, what PPE should we use? The type of patients our service conveys, and the advanced treatments we provide, means there is a higher likelihood that a patient’s conscious is already at a reduced level or may deteriorate further in flight and therefore require interventions classed as Aerosol Generation Procedures (AGP), such as CPR, using suction to unblock a patients airway or delivering manual ventilation to a patient that isn’t breathing. Public Health England’s guidance is that Level 3 PPE should be worn during all AGPs. How can we apply social distancing rules in our aircraft if we can’t use PPE in flight? Social distancing is now a regular feature of our day to day lives however it is not possible to provide a 2m buffer between the pilots and medical staff within the close confines of our EC 135 helicopters (in fact our medical teams, pilots and patient are all within about 1m of each other in flight). Presumably then we could simply provide the aircrew with PPE? Yes, and we have. However, unfortunately, as Level 3 PPE is not flame retardant to aviation safety standards, our crew are not permitted to wear full PPE in flight. Also, the safety flying helmets the crew have to wear, again to comply with the aviation safety regulations, do not physically enable full face visors to be worn (essential in avoiding respiratory droplets when treating patients up close). Are there any other challenges around flying with PPE? Yes, the respiratory protection masks and powered respirators do not work effectively with aircraft communication microphones. So, if the crew were wearing a face mask the ability to talk to one another or communicate externally to air traffic control for example is more difficult and could reduce levels of safety. Why not just treat those patients who don’t have Coronavirus? There is no validated pre-hospital screening tool or test which can ascertain a patient’s Coronavirus status. As Public Health England have confirmed many Coronavirus positive patients display no symptoms, but still remain infectious, there is no safe way to determine if a patient has Coronavirus or not. What about the aircraft – can’t you retrofit a solution? At this point in time, there is no approved physical screening solution to separate the pilot from the patient treatment area inside any HEMS aircraft. We are currently working with a number of agencies to produce solutions to a number of the outstanding issues, some are quicker fixes than others but a great deal of co-ordination across the sector is evident. Ok, after considering all these factors, what next? It was clear to us that without the ability to wear adequate PPE in flight, our crews would potentially be exposed to an increased risk of contracting Coronavirus. Furthermore, with an incubation period of around 2-weeks, an infected member of staff could potentially infect many patients, other staff and other healthcare professionals during that period. In a relatively short period of time that could have a real impact on our patients, hospitals, treatment centres and frontline NHS colleagues. That risk, particularly to our patients whose health condition often places them in a vulnerable position, in our opinion is just too great. The good news is that, after taking the decision to temporarily stand down the aircraft, we immediately switched our Patient Services team onto our two Critical Care Cars. These vehicles, equipped with the same medical equipment as our helicopters, are now strategically placed to cover Devon, with the two-person crews delivering enhanced emergency prehospital care from 7am until 2am the following day. By the end of last week, our team had already responded to 49 patients in this way, bringing real, tangible benefits to our local communities. In our next Blog we’ll be focussing on the huge amount of positive work being carried out by our Helicopter Services team, who are working across the aviation sector to develop solutions to tackle some of the issues we have identified. We’ll also look at how our Patient Services team are developing new ways to employ their skills, experience and time to help the fight against Coronavirus and protect our NHS. More on that can be found in our recent News.