In this issue of the Internal Medicine Journal, Gardiner et al.1 offer valuable lessons from their considered and comprehensive analyses of aeromedical retrieval patterns for the whole Royal Flying Doctor Service (RFDS) network during the 7 weeks before, during and after, Australia's COVID-19 restrictions imposed between 16 March and 4 May 2020. Gardiner2 had previously modelled that if COVID-19 transfers were to increase to a threshold of 10 patients per day per RFDS area of operation, Australia's Hospital in the Air's current fleet of 77 aircraft across its 23 Australian bases would not be able to satisfy this insuperable COVID-19 workload demand. Low-priority transfers and patient repatriations would face delays until the COVID-19 surge back-log was able to cleared. Fortunately, COVID-19's worst-case disaster scenario2 did not eventuate for the RFDS. Nevertheless, COVID-19's conflagration into a global public health threat incited aeromedical services worldwide to rapidly protocolise and simulation-train locally adapted personal protective equipment (PPE) policy, safe advanced airway management, aircraft disinfection and rescue base social habits,3 with the support of the Air Medical Physician Association.4 On aircraft taking off, both retrieval staff and patients endure the cross-contagion impost of hours-long cocooned confinement within a small air ambulance cabin. The RFDS transported six confirmed and 230 suspected COVID-19 cases during the whole study period. No confirmed, and 13 and 4 suspected COVID-19 patients, respectively, required intubation and non-invasive ventilation during the study period.1 Long periods of encasement in PPE inflicts fatigue, heat stress, degrades cognitive performance, hinders life-saving medical procedures and interpersonal communication in a constrained, noisy and vibrating aircraft cabin.5, 6 The Swiss air rescue Rega have deployed a portable patient isolation unit (PIU) to reduce the amount of PPE staff are required to wear while still allowing good access to the patient.6 A PIU potentially enables safer long-haul RFDS transfers of patients with COVID-19 and other highly contagious infectious disease. Doctors, nurses, air-crew and clinical coordination staff and their patients, some of whom required medical escorts for critical illness or severe injury,1 together braved the COVID-19 head-wind of potentially reduced access to on-scene resuscitation and time-critical transfer for percutaneous coronary intervention and stroke reperfusion. Some staff would require isolation, and aircraft would need COVID-19 disinfection.3-6 Fortunately the RFDS experienced substantial reduction in acute coronary syndrome (ACS) transfers during the restriction. This demand rebounded soon afterward.1 Similarly, the Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) study observed a worrying 12.6% decrease in STEMI presentations and interhospital transfers during the pandemic peak in regional Germany.7 The RFDS is encouraged to access cardiology unit registries to determine whether the post-restriction ACS 'rebound' cohort in rural and remote Australia suffered higher risk of a major adverse cardiovascular event at 90 days. Seeking cardiac care late is reasonably attributed to fear of catching COVID-19 during the restriction period. Retrievals for cerebrovascular disease remained stable through the three study periods. One-quarter to one-third of these cases were assigned high acuity requiring P1 medical escort.1 This urgent RFDS clinical prioritisation aligns with time-critical improved outcomes experienced by rural and remote patients with large vessel occlusion stroke transferred to a Perth thrombectomy unit, even with the huge travel distances in Western Australia.8 Longer air ambulance transfers are associated with reduced eligibility for thrombectomy.9 The demand for stroke reperfusion and thrombectomy plummeted among Western Europe's stroke centres during the pandemic peak, with patients suffering delays to definitive care.10 Australia's rural patients are similarly fearful of seeking care for stroke symptoms. This fear coupled with increased retrieval demand during future COVID-19 resurgence requires RFDS vigilance to try to maintain high standards in time-critical stroke care retrievals. Increased transfers of infants with congenital cardiovascular malformations during lockdown were attributed to closure of proximate regional paediatric cardiac centres.1 Four of five children admitted to paediatric intensive care units in Canada and the United States with COVID-19 had significant co-morbidities and two of five required intubation.11 The intersection between care for children with severe congenital heart disease by air ambulance crews,12 risk of COVID-19 cross-infection in such vulnerable children,11 as well as altitude and ambient stress during neonatal transport,13 is concerning. RFDS psychiatric retrievals declined during, then rebounded after, Australia's lockdown.1 This pattern should be viewed in the pre-pandemic context of mental health and behavioural disorders among rural and remote communities already needing a high number of RFDS retrievals.14 Social isolation, alcohol and recreational drug use, worsened by COVID-19, led to rapid mental health congestion in northern Italy's acute psychiatric facilities.15 The anticipated post-restriction mental health surge could stress the RFDS further. Mental health transfers in the Northern Territory in 2014 required a lengthy 4.5 h, with four of five patients requiring in-flight sedation.16 Endocrine emergencies, particularly poorly controlled diabetes mellitus (DM), was unaffected by COVID restrictions. It is also worrying that retrievals for renal failure increased during and after the restriction period. The authors rightly stress that DM,1 and renal failure, are co-morbidities associated with worse COVID outcomes. Pre-pandemic suboptimal access to kidney disease management services in Aboriginal patients in rural Australia, associated with increased aeromedical retrievals for acute renal care,17 is sure to be compounded by COVID-19's systemic disruptions. To be forewarned is to be prepared, yet there is nascent hope on the COVID horizon. Strategies to mitigate the catch-up surge in cardiac care demand after the restriction are feasible. Remote risk stratification within long-established regionalised clinical cardiac support network, 18 as well as point of care echocardiography images acquired by non-specialist clinicians19 for assessment by tele-cardiologists, could help a stressed retrieval system. Importantly, risk assessment could avert unnecessary chest pain transfers by better identifying then transporting only high risk ACS patients.19 Tele-cardiology has proven benefits in the post-discharge care of patients with heart failure, arrhythmias and implantable devices.20 Tele-psychiatry has a reputation for safely averting unnecessary patient transfers and is cost-effective.21 Gardiner and colleagues1 remind us that reduced rates of non-COVID-19 respiratory illness requiring RFDS retrieval could only have been achieved by the social distancing and meticulous personal hygiene incited by COVID-19. This is a silver lining of precious optimism during these past 9 months of dark threatening skies buffeting Australia's ‘hospital in the sky’.