As COVID-19 sweeps across Ontario, the province’s air ambulance service is rapidly boosting its capacity to transport critically sick patients and vital medical supplies during the pandemic.

The service — known as ORNGE — is preparing to transport hundreds of sick patients with COVID-19, many requiring ventilators and specialized care, from across Canada’s second-largest province, an area covering more than one million square kilometres.

Its transport vehicles, staffed by critical care paramedics, are particularly important for Ontario’s rural and remote regions and many Indigenous communities that don’t have the same medical resources as urban hospitals. Doctors in those regions warn that just one or two very sick patients with COVID-19 will overwhelm small hospitals and clinics, many of which have few or no ventilators.

“We are the primary support for the province’s remote and rural regions,” said Dr. Homer Tien, president and CEO of ORNGE. “Hopefully the surge in patients we are planning for won’t happen to the extent we’re fearing. All we can do until then is plan for contingencies and make sure our resources are as augmented as possible.”

Tien, who sits with other health-care leaders at the province’s “COVID-19 Command Table,” said ORNGE is working closely with Toronto Paramedic Services to prepare for an anticipated surge in coronavirus patients in the GTA. This could include using the city’s ambulance bus to transport many critically ill patients at once between Toronto’s 13 hospitals, he said.

During the last week, ORNGE has transported patients, primarily in the GTA, who have or who are suspected to have COVID-19, said Tien.

In anticipation of a spike in transport calls, Tien said ORNGE is looking to hire additional qualified pilots for its aircraft to increase the number of flights it can make.

The service is also adding critical care land transport vehicles to some of its routes, including one that will operate out of Hamilton to move patients in the Niagara Peninsula, and one based in Chatham-Kent for the London-Windsor-Sarnia corridor.

ORNGE operates out of 12 bases in Ontario, including Kenora, Sioux Lookout, Thunder Bay, Timmins, Sudbury and Moosonee in the north, and London, Peterborough, Ottawa and two Toronto-area bases in the south. It has eight airplanes, 12 helicopters and 13 critical care land ambulances that are outfitted to transport patients who require advanced care and critical care, including ventilation.

Tien said the province has recently granted ORNGE permission to modify how it staffs its vehicles as a way to increase the number of transports the service can do in a day. Normally, two critical care paramedics — those with the highest certification and the ability to intubate and care for patients on a mechanical ventilator — are required to ride with a patient in the back of an air or land ambulance.

Now, if needed, a critical care paramedic can be paired with a primary or advanced care paramedic, Tien said, adding there are fewer critical care paramedics than either primary or advanced care paramedics.

“This change means we can theoretically staff two critical care ambulances instead of one,” he said. “If we’re in a major patient surge, this will be important.”

In Toronto, Chief Gord McEachen, general manager of the city’s paramedic services, is closely watching how paramedic services are coping in other regions of the world already hit hard by COVID-19. In recent days, New York City, the current epicentre of the outbreak in the United States, has reported its ambulances running at historic levels with paramedics speaking out about not being able to transport or treat all the patients who require help.

While this is not yet the case in Ontario, health officials warn infections in the province have not yet peaked and the next two weeks are critical to “flatten the curve” to slow the spread of COVID-19 and keep hospitals and paramedics from being overwhelmed by sick patients. On Monday, Ontario’s associate chief medical officer of health, Dr. Barbara Yaffe, said there are currently 100 people confirmed to have COVID-19 in intensive-care units, 61 of them on ventilators.

McEachen said he’s confident Toronto’s paramedic services will be able to keep up with demand during the COVID-19 pandemic, pointing to its highly trained paramedic staff and the detailed 911 triage protocols dispatchers use to deploy ambulances to the right place at the right time, thereby conserving resources.

As part of its COVID-19 preparations, McEachen said the service recently converted its ambulance bus from a vehicle that usually transports mildly or moderately ill patients to a vehicle that can transport up to eight patients on stretchers and who may require ventilation.

McEachen said Toronto paramedic services has enough personal protection equipment for its paramedics and that their COVID-19 protocols are updated constantly, according to information provided by the province’s public health agency.

At ORNGE, Tien, a trauma surgeon, said the service is working with its paramedics to problem-solve how best to help rural and remote hospitals and clinics, as well as fly-in communities in the province’s north, during the COVID-19 pandemic.

Among the plans is to increase its 24/7 telemedicine service, staffed by an emergency physician, to allow rural and remote doctors to get immediate advice on how to care for a critically ill patient.

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ORNGE is working with the province so that its aircraft could be used to transport medical staff and supplies, including backup ventilators, to remote regions, as well as to fly completed COVID-19 tests from the north to laboratories in southern Ontario, Tien said.

Though plans are in constant flux as the COVID-19 pandemic progresses, Tien said his foremost worry is for the air ambulance pilots and paramedics should there be a rapid spike in coronavirus patients.

“What keeps me up at night is that all our health-care workers get infected, burn out or both. That’s why we need to be prepared.”