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From Toronto Star

Air ambulances a lifeline for the North - Ontario's air ambulance system, Ornge, is critical for the 800,000 people living north of Sudbury

March 29, 2009 - Megan Ogilvie - HEALTH REPORTER

SIOUX LOOKOUT, ONT. – The King Air 200 grinds to a stop.

Within moments, Marc-André Charbonneau cracks open the door of the twin-engine turboprop and steps onto the gravel strip.

It is dark and cold and still.

Charbonneau and his two fellow flight paramedics hear the car before they see it. First a crunch of frozen gravel, a swing of headlights onto the strip, and then a beat-up brown minivan emerges from the dark and pulls up beside the plane.

Inside is a young mother and her sick baby boy. The only way he can see a doctor tonight is to fly more than 500 kilometres out of Sandy Lake, a remote community in northern Ontario, to the children's hospital in Winnipeg.

The 6-week-old has severe jaundice, a condition that if left untreated can lead to long-term brain damage and even death. And this evening his glucose levels have plummeted, a sign that something could be very wrong.

The paramedics know little else about their patient crying inside the van, this community's version of an ambulance. But there is one certainty on this midnight flight: every minute counts.

Sandy Lake First Nation is locked in dense boreal forest thick with spruce, tamarack and ash. Like many other northern communities, no roads lead in or out of town, and its some 2,650 residents depend upon a single gravel airstrip for much of their food, supplies and building equipment.

It is also their only lifeline to medical care.

In northern Ontario, air ambulance crews must overcome great distances to ensure the 800,000 Ontarians who live north of Sudbury get the same level of care as the 12 million living in the south.

Crews in Kenora, Thunder Bay, Timmins, Sudbury and Moosonee also respond to calls in the North. But paramedics at Sioux Lookout are largely responsible for the 30 remote communities scattered above Pickle Lake, the "end of the road" township of 350 where paved highway peters out into bush.

Flight paramedics in the North, particularly the 13 based in Sioux Lookout, must combine highly tuned medical skills with resourcefulness and stamina. In many ways, they do frontier medicine in a modern society.

Unlike southern Ontario, there are no land paramedics to assess and stabilize patients. Patients are brought to nursing stations in the back of pickup trucks, or transported out of the wilderness on boats, float planes or snowmobiles.

There is no reliable weather reporting north of Sioux Lookout, and pilots often rely on first-person accounts to assess conditions at their destination. They might ask a nurse to step outside the station to test the depth of snow on the ground, or to describe how fast clouds are moving across the sky.

Nursing stations may or may not have a nurse, which means paramedics go to work knowing little about a patient's condition. In the south, flight paramedics often have a patient's medical history sent to their BlackBerry or radioed to the aircraft before they arrive at the scene, which means they can start preparing for a case before they even see a patient.

"No matter where you are in southern Ontario, you are 30 minutes away from an ER," says Mike Rumble, an advanced care flight paramedic from London, Ont., who is on a six-week residency in Sioux Lookout. "Up here, we don't have that safety net."

THE SIDE DOOR of the van slides open, and Charbonneau leans inside to get his first look at the baby.

The rest of the team is already in action: Rumble is questioning the nurse about the baby's condition. The pilot is calculating whether the small airplane can fly with the extra weight. And inside the cabin, the third paramedic, Ray Dewar, is double-checking supplies.

After a thumbs-up from the pilot, the young mom climbs out of the van clutching a baby carrier. Her little boy, wrapped tightly in a bright green blanket, cries weakly.

Minutes later, the plane begins to rumble as first one propeller, then the second, start up.

"Ready for takeoff?" the pilot asks over the radio, as he steers the plane onto the gravel strip.

"We are secure for takeoff," answers Charbonneau, turning off the cabin's overhead lights.

The rumbling turns into a raging whine as the plane streaks down the strip and lifts into the darkness. The crew is pleased: Only 13 minutes have passed between landing and takeoff.

This is the fifth baby for the 28-year-old mom. She tells Charbonneau that her husband, who has no idea anything is wrong, is in the bush hunting for a moose to celebrate the birth of his first son.

As Charbonneau checks the baby's vital signs, Rumble flicks on the radio to update the Ornge air ambulance system's communication centre in Toronto. Then he flips through the baby's chart one more time. "This is a very sick little boy," he says.

PARAMEDIC CREWS in Sioux Lookout are often called to evacuate expectant moms and young children from northern communities. These are the two groups of patients that can quickly slide from stable to critical condition.

Earlier in the day, critical care flight paramedics Ron Laverty and Victoria Irwin also responded to a call in Sandy Lake, this time to transport a woman 33 weeks pregnant with her tenth baby.

Rhonda Goodman came to the nursing station complaining of back pains. The nurse, who did a pelvic exam and found blood on the vaginal wall, immediately called for flight paramedics. She feared there might be a ruptured placenta or placenta previa, conditions which could threaten the life of Goodman and her baby.

Laverty and Irwin, who between them have more than 20 years experience in the North, monitored their patient throughout the 55-minute flight to Women's Hospital in Winnipeg. And though the fetal heart rate was slightly lower than normal – a potential sign of distress – the critical case did not turn into an emergency.

Obstetric calls are so common in the North that every paramedic in Sioux Lookout has delivered a baby en route to hospital.

It can be wonderful, says Laverty, to welcome a new life on a plane. Other times, it can be one of the most difficult calls paramedics face, says Dewar, who now works at Ornge's critical care land program in Ottawa.

"It's the call I dread," he says. "Nine times out of 10, mom is going to have the baby the way they have been forever and everything is fine. But it's that one time where the baby might come out and need some work and mom is bleeding and needs work. So all of a sudden, you have two patients that could be serious, and there is only two of you in the back. There's no help, no teams. It's just you and your partner."

The paramedics at Sioux Lookout are quick to point out that, whenever possible, it is best to transport a patient before the situation becomes perilous, before the baby with jaundice has seizures, or before the expectant mom needs a life-saving Caesarean section.

In the North, the combination of great distance and unreliable weather reporting can make quick transport close to impossible. Paramedics know if they don't fly in when the weather is clear, even if a patient is not yet critical, that window may suddenly close up until it is too late. "Sometimes you can't get in," says Laverty, "and sometimes people die or have a very poor outcome because they can't get to a hospital in time."

Paramedics bring that same pragmatism, coupled with a frontier creativity, to trauma calls. It could be a head injury from a snowmobile accident, or third-degree burns from an exploding propane heater or hypothermia from a hunting trip gone wrong.

Whatever the call, Irwin says flight paramedics often start from scratch, since most nursing stations are geared to primary care and not emergencies.

It is critical paramedics start to improve a patient's condition right away. Trauma experts often refer to the "golden hour," an optimal period of time to treat an injured patient before their condition deteriorates past a treatable point.

In northern Ontario, paramedics have a golden half day. Precious hours will already have passed by the time they see a patient, and there are likely hours more to go before they can get to the hospital.

EVEN BEFORE the engines chug to a halt, an ambulance, its red lights flashing, pulls up to the plane. This time, Charbonneau clutches the baby carrier and descends onto the tarmac. He quickly tucks the green blanket around the infant's face to protect it from the whipping wind.

"Ugh. It's windy," says Dewar with a grimace. "Typical Winnipeg."

The baby, who slept for most of the plane ride, is now wailing, each cry catching in his throat.

Charbonneau has not left the pair's side since escorting them from the van in Sandy Lake. Even now, minutes away from hospital, he monitors the baby's condition, afraid it could deteriorate.

But soon, less than 40 minutes after landing at the Winnipeg airport, the mom and baby are signed over to the care of a pediatric emergency physician. Charbonneau wheels mother and baby into an examining room, checks one last time that everything is okay, and smiles.

"You take care," he says, patting her on the shoulder.

Like all flight paramedics, Charbonneau will never know what happened to his patient.

Dewar and Rumble check their watches. It's only 2:05 a.m., just enough time to take another call before their shift ends at 6 a.m. Dewar is betting on a trauma call. It is a Friday night after all, and the bars have just closed.

Rumble calls Ornge's communication centre from a bank of pay phones near the front entrance of the ER. He returns with a smile. The crew from Kenora has taken the single trauma call in the area, and Charbonneau, Rumble and Dewar have been called back to Sioux Lookout.

The three paramedics grab their flight bags and head outside to hail a cab back to the airport. Tonight, they will sleep stretched out in the back of the darkened airplane cabin, illuminated only by the blue-green glow of the northern lights.

That is another lesson learned on the job: Grab sleep when you can. There may be another call waiting in Sioux Lookout.