Features Commercial EMS
Wings of Life

Ornge S-76 coming in to land on a rooftop helipad at Hamilton Health Services.

While  its new name is intentionally misspelled, there’s nothing whimsical about Ornge – the former Ontario Air Ambulance Service – as it crosses the province providing lifesaving transport to hospital patients and accident victims alike.

It was late. You were tired. Rushing down that secondary road flanked by the woodlands of central Ontario, you never saw the deer that darted out in front of you and can’t remember what happened next. It’s now dawn, and, in your semiconscious state, you are vaguely aware of muffled voices and other people around you, although you have no idea how you got out of the wreckage that until recently was your car.

You’re lying on a litter and you hurt. Bad. The shock is keeping panic at bay for now, but you sense that you need to get to a hospital…fast. Then a new dull, throbbing sound intrudes, and, even with your head immobilized in a neck brace, you can spot something up in the morning sky. It’s a helicopter, growing larger as it descends. It’s shiny…it’s loud…and it’s orange.

“That crash-on-the-highway medevac scenario is likely what the average person envisions when they think of an air ambulance service, but while we certainly do those ‘trauma calls’ regularly, they’re only about 20 per cent of our annual missions logged,” says Dr. Chris Mazza, president and CEO of Toronto-based Ornge, the uniquely named private company that before 2006 was known as Ontario Air Ambulance. “The other 80 per cent of the approximately 18,000 calls we accept each year consist of aerial transport of critically ill patients already in a hospital who need to be transferred to another facility, and whose condition – or the distances involved – make land transport in an ambulance impracticable.”

Contracted exclusively by the Ontario Ministry of Health and Long-Term Care, Ornge comprises a carefully integrated system of more than 300 employees – about 180 of whom are front-line paramedics with either Primary Care, Advanced Care or Critical Care certification. The aviation component – there’s also a land-ambulance operation – is subcontracted to Canadian Helicopters Ltd., which provides and maintains the aircraft and actually employs the pilots (the medics aboard the aircraft, however, are Ornge employees).
Ornge also operates a highly sophisticated flight-paramedic and flight-nurse training arm called the Ornge Academy of Transport Medicine.

“I trained in Transport Medicine in both Canada and the United States,” Mazza says, “and ultimately joined Toronto’s Sunnybrook Hospital as a trauma team leader in the Emergency Department. In 1997, the position of director of Sunnybrook’s ‘aviation base’ operation came up, and I was selected for it. I’d always been fascinated by aviation – I’d taken some fixed-wing flying lessons in my younger years – and at that time Sunnybrook pretty much oversaw the air medical-evacuation activities for all the Toronto-area hospitals.”

Mazza found in the ensuing years that there was a lack of overall coordination across Ontario with respect to aviation transport medicine, with too many bureaucratic entities and not enough common vision and  cooperation, even though medical air transport in the province dated back to 1977.

“I started pushing the idea that this was really all just one product,  and at the end of the day it was more about patients and health care than aviation. By 2002-2003, the organizational concept that became Ornge started to come together, and in 2005 the various entities were combined by the provincial government, with Ornge coming into existence – although not known by that name for another seven months – on Jan. 1, 2006,” he recalls.

Mazza explains that the “misspelling” of “Orange” was very intentional.

Ornge Sikorsky pilot Peter Cunnington.
Dr. Chris Mazza is president and CEO of Toronto-based Ornge.

“Emergency medical vehicles have traditionally been marked in whole or in part with International Orange, for high visibility,” he says. “Our helicopters and fixed-wing aircraft had always had some orange areas – and in the future they’ll be primarily that colour – and so taking that symbology as our corporate name made sense. However, the unfortunate fact is that many people across Ontario – even in the medical profession and the media – still do not really understand who we are and everything we do, so we figured if we dropped the ‘a’ from our name, people would do a double-take and maybe investigate a bit more about this company that was ‘…too stupid to know how to spell orange’!”

The air assets of Ornge currently consist of 11 Sikorsky S-76 helicopters (with the assumption that eight will be serviceable for missions at any given time), two Beech King Air 200s and one Pilatus PC-12. The helicopters are based at seven locations around Ontario: Toronto Island (i.e., City Centre Airport), London, Ottawa, Sudbury, Thunder Bay, Kenora and Moosonee. The fixed-wing aircraft are at Thunder Bay (Pilatus), Sioux Lookout (Beech) and Timmins (Beech), and only operate from proper airfields, so are mainly employed for facility-to-facility patient transport rather than on-scene calls, although occasionally trauma-response missions are undertaken into First Nations reserves that have airstrips.

Each base has at least one AME available for routine maintenance, but the aircraft are also periodically rotated to different bases to even out the number of flight hours and engine cycles, since mission intensity varies from base to base.

Big change is on the horizon for Ornge, since both the rotary-wing and fixed-wing fleets will be replaced with new-generation aircraft in the near future, and – for the first time – Ornge will actually own its aircraft instead of leasing them. The aviation component of Ornge’s overall budget is about $120 million a year, and owning the aircraft was determined to be much more cost-effective. Ornge vice-president/aviation Rick Potter explains further:
“Our Sikorskys are 25 to 30 years old, with all the increased maintenance costs that this implies, and the fixed-wing equipment is in a similar status,” he says. “As a result, we’ve decided to acquire ten Agusta AW-139s as our new helicopter platform, and six Pilatus PC-12-47NGs for our fixed-wing requirements.”

The helicopter purchase – worth about $130 million – was announced in August 2008, and the Pilatus purchase, budgeted at $35 million, was announced in October.

“We hope to have the Pilatus operational by mid-2009, and the Agustas by the end of 2010,” Potter adds. “This re-equipment will give us aircraft with longer range, and – especially with the Agusta – the ability to operate in a wider range of weather conditions, especially regarding routes where there’s a risk of icing.”

During the phase-in period, Ornge will have to fly both the new types and the “legacy” aircraft, but the plan calls for only one aircraft type to be at any given base at a time. There’s been no decision made yet as to whether the new fleets will mean a change in the number or location of bases. While the new aircraft will be owned by Ornge, the pilots and maintainers will still come from CHL.

When the Ornge Academy of Transport Medicine was established, the company took a number of training tips from the aviation world.

“Professional aviation has been a longtime leader in the use of simulators, and we could see that this was how we needed to go,” says VP/Operations Tom Lepine. “At the Ornge Academy, we require that a student already have the Basic Paramedic certification – which typically requires a two-year community-college course – and then we train them in the aircrew-specific aspects of patient care as well as offering flight-oriented courses to upgrade to Advanced and Critical Care professional qualifications.

“We realized that it wasn’t feasible to require that our paramedics come to Toronto for these courses, since we need them on the job at their own bases, so we take the training to them both through computer-based distance-learning courses and a very sophisticated simulator that goes from base to base for hands-on training.”

That simulator – which looks like a typical commercial tractor-trailer rig from the outside – consists of an accurate full-size replica of the passenger cabin of a medevac S-76. All the medical-related equipment actually works, and there’s a highly sophisticated patient mannequin that can mimic 180 human physiologic variables in real time.

“It breathes, its pupils dilate, it blinks, it talks…this is one state-of-the-art training aid,” Lepine says. “Our goal is to provide a medevac training environment that – to the student – is exactly like the real thing.”

In 2008, the Ornge Academy graduated 60 students, representing all of their various levels of certification.

Sitting in the “ready room” at the Ornge base at Toronto City Centre Airport on a cold December evening, Sikorsky pilot Peter Cunnington, 36, reflects on the aviation background that ultimately brought him to work at Canadian Helicopters on Ornge duties in April 2002, where he’s so far logged about 2,500 hours.

“I’d always been fascinated by airplanes, and as a kid I planned to be an airline pilot,” he says. “After I’d snagged a couple rides on helicopters, however, I was hooked on rotary-wing. After I graduated from the University of Western Ontario, I worked my way though a commercial helicopter licence at Carp, Ontario, in 1997, and then first got hired as a ‘ramp rat’ on ground duties at Helijet in Vancouver.

Helijet liked to see its neophyte pilots work their own way up, so Cunnington got his rotary-wing IFR and ATP licence at his own expense while pumping fuel and humping luggage on the ramp at Vancouver International. By early 1998, he’d been taken on as a first officer at Helijet, flying S-76s.

“The flights were all within B.C., and I was logging about 750 hours a year, which was great for building up time,” he recalls. “While I was with Helijet, they got the air ambulance contract for a section of B.C., and I moved over into that duty as a first officer, since by then I had the 1,000 hours minimum they required. After four years at Helijet, I left and did some ‘heli-logging’ flying out west, and then came back to Toronto and joined CHL and Ornge as an aircraft captain. I was already proficiency-checked on the S-76, of course, so it was a pretty seamless transition as far as the aircraft went.”

The crews at Toronto Island work 12 to 14 twelve-hour shifts in a month, half of them days (7 a.m.-7 p.m.) and half nights. Ornge has an around-the-clock Communications Centre (with flight-medicine physicians on hand to evaluate and prioritize the calls as they come in), and it’s the Ornge dispatcher who’s on the line when the phone rings. As at any Ornge base, the crews can accept or decline any given call, usually based on weather conditions.

“Our weather criteria vary between day and night calls,” Cunnington notes. “At night, our Minimum Obstacle Clearance Altitude is 1,000 feet above any obstacle within three nautical miles of that route’s centreline, and our company database of routes is all predicated on GPS-direct. In daytime, things are less restrictive, but we want to maintain a minimum 500 feet AGL, with exceptions when we’re over built-up areas.”

Company policy calls for an aircraft to be airborne within 10 minutes of accepting a call, although the need to file IFR can extend that timeframe somewhat. The Sikorskys flight-plan for a 30-minute fuel reserve at night, and 20 minutes in daytime. Each base has roughly a 100-nm radius in which most of its missions are flown, but there are always exceptions.
“Out of Toronto Island, we typically operate in an arc from London in the west to Huntsville in the north to Kingston in the east,” Cunnington says. “However, I’ve flown to Detroit/Windsor, Cleveland, Sault. Ste. Marie, Sudbury, Ottawa and similar destinations.

“Most of us pilots like the variety in this work,” he adds. “I remember a call that started out being a simple patient transport from Owen Sound to London, so we flew there VFR, got the patient, and then found that London had deteriorated to IFR. So we ended up shooting an ILS approach to minimums at London.

“Just as we offloaded the patient, our beepers went off and we were given a trauma-call assignment out somewhere in Algonquin Park, where the weather was nice. We departed London IFR, landed in Midland to refuel, then departed VFR into Algonquin. We had to land in a confined area in the bush to get the patient, then arrived back in Toronto after dark. That was a long day.”

Navigation to locate a casualty in woodlands or bush areas used to be a real challenge, but the increasing availability of GPS and satellite phones has helped a lot.

“When you go on a scene call, even if it’s on a roadway, you never know exactly where you’ll be able to land until you get there,” Cunnington notes. “Sometimes the police or fire department already at the scene are surprisingly well-trained and well-equipped to select and mark a landing zone, and, other times, we’re pretty much on our own.”

Flying onto rooftop pads at hospitals can be tricky if the winds are gusty, he observes, with St. Michael’s Hospital in downtown Toronto being especially challenging.

“It’s not much different from landing on a mountaintop,” he says. “You have to assess what effect the nearby buildings are having on the wind, and the windsock at the pad only helps so much. Yesterday, we landed on the roof of St. Mike’s in 30-knot winds and it was fine, because it was directly on our nose, coming down the corridor of those buildings. But had the wind been 30 degrees off from my right, we wouldn’t have gotten in there…it would have been way too turbulent.

“I love my job, and I think virtually all the other pilots do, too,” Cunnington says. “It’s rewarding to help people…the flying varies with every shift…and I can be home with my wife at some point each day. It’s never a chore to come to work.”

From the CEO and other senior management to the pilots and paramedics at the pointy end, there’s a very obvious common thread in the Ornge operation, as summed up by Chris Mazza:
“Our goal every day is to offer our patient-transport passengers at least the same level of care they were getting at the hospital they’d just left, and to give trauma-call patients the best-possible care until they arrive at the receiving medical facility. We see ourselves as a ‘virtual hospital,’ not just a transportation service.”