During the COVID-19 pandemic, extracorporeal membrane oxygenation—better known as ECMO—has been a key treatment for some of the sickest COVID patients. ECMO essentially provides patient with an external heart and lungs, circulating and oxygenating the blood while allowing medical teams to treat those essential organs. Does that mean ECMO is also the future of cardiac arrest care?
The Minnesota Mobile Resuscitation Consortium, a collaboration of cardiologists, emergency physicians and EMS, is showing that ECMO might be an important link in the chain of survival for certain patients with sudden cardiac arrest. Initial studies showed that the survival rate in patients with refractory ventricular fibrillation—in other words, patients with shockable rhythms who didn’t respond to defibrillation—was significantly higher when they were treated quickly with ECMO compared to standard ACLS. The concept actually sounds rather simple: put these patients on ECMO so their brain and other vital organs are kept alive while the source of their cardiac arrest can be identified and reversed. But getting these patients on ECMO quickly is a bit more complicated.
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In the first phases of the program, patients were taken to one of three hospitals and met there by a specialized mobile ECMO team. The next phase will launch a new, state-of-the-art mobile ECMO truck that will allow the team to meet EMS and the patient in the field and start the ECMO process earlier.
We sat down with Ralph Frascone, MD, and Bjorn Peterson, MD, two of the local EMS medical directors involved with the Minnesota Mobile ECMO Program, to find out more about implementing ECMO for cardiac arrest in their systems and what the future holds.
JEMS: Was this a big shift for your systems, to go from “We do everything the hospital can do for cardiac arrest patients” to instead transporting these patients after only a few minutes of resuscitation to get them on ECMO quickly?
Peterson: You know, we’ve been doing this for several years—about five or six—and so I honestly don’t even remember the “pre-ECMO world” around here. I think they key was with Dr. [Demetri] Yannopoulos. He’s such an engaging guy, and he welcomes the EMS crews, they deliver the patient directly to the cath lab where he is. And he lets them observe him cannulating the patient and starting ECMO. It just took one or two of our crews seeing that and seeing the outcomes. The word spread like wildfire, and we had nearly universal buy-in.
Frascone: Seeing the positive results reinforces the behavior. But it’s still a drastic paradigm shift for how you treat cardiac arrest in the field. These kind of medical cardiac arrest patients were the ones we stayed on scene with, and now we’re telling the medics to transport. And we have to keep working at it, we have to keep telling them that we have to move faster. Time cost lives, and unlike the old days of working a cardiac arrest for 30 minutes in the field, we’re asking them to do pretty much the opposite and work an arrest on the way to the hospital. One of the things I’ve been preaching is they should pretend this is a gunshot wound to the chest.
Peterson: We’re kind of going away from the ACLS playbook, and we’re saying there’s a big difference between PEA/asystole and a shockable rhythm. And if it’s VFib, like Dr. Frascone said, you treat it like a trauma scene, and you recognize that there is a definitive treatment that the hospital can potentially offer that you can’t in the field.
JEMS: You mentioned Dr. Demetri Yannopoulos, who’s one of the leading researchers and advocates for improving cardiac arrest care among cardiologists worldwide. Not every community has a leading ECMO researcher pushing for programs like these. How should EMS leaders interested in introducing ECMO into the cardiac arrest system of care in their communities get started?
Frascone: Well, EMS is who brings the patients in, and so you have to understand that medical directors have a lot of power to influence hospitals, particularly in areas where they determine triage and transport guidelines. But the more important thing is that you have to already have something in place to implement a program like this, and that’s a desire to collaborate and to put patients first. I know it sounds kind of hackneyed, but in fact, that’s what’s been driving this program from the beginning.
When Dr. Yannopoulos and I and the other members of the team explained to leadership at other hospitals why we weren’t taking VFib patients to them, and instead going to the ECMO hospital, we showed them the data—that with ECMO, the patients’ chances of survival was more than 40 percent, versus 5 or 10 percent at their hospital. And their answer was, ‘You’re doing the right thing.’ That sort of collaboration, where the patient comes first, has to be in place before the system has any chance of working at all.
We also didn’t rush into this. We took a step-by-step approach, starting with ECMO at one hospital. Then the second step was mobilizing the ECMO team to a few other hospitals. We’re only now getting ready to do this in a mobile vehicle that can meet people on the scene or in a parking lot and do ECMO outside of the hospital. And there were tons of challenges—logistical, legal, etc. We didn’t just rush in and say ‘We’re going to get this cool truck and do ECMO in the field and that’s the way it is.’
Peterson: Dr. Yannopoulos also did a great job, meeting with the CEOs of all the hospitals and convincing them of the value of this program, and that it was about patients and not trying to steal business away from them.
Frascone: He understood that you do this kind of change from the top down, not the bottom up.
JEMS: So why is it so important that this be collaborative? What if multiple hospitals in a community established ECMO programs for cardiac arrest—wouldn’t that open this up to more patients?
Frascone: From the beginning, this has been viewed as a community resource, and structured that way for several reasons. One critical reason is the experience that each ECMO cannulator gets. And I think the hospitals, at least smaller hospitals, will understand that it’s not practical for them to have this sort of capability inside their own institution, and will instead use the community resource.
Peterson: I think that’s a huge part of this, and being able to reproduce the success we’ve had in Minnesota, having a small group of people who are proficient at cannulation. It needs to happen in 15 minutes or less, and you can’t expect dozens of people to be able to do that if they’re aren’t doing it frequently. A big part also is having a single ICU, with the expertise in managing ECMO patients, and recognizing the impact of cardiac arrest on the brain and the length of time it takes to recover.
JEMS: Much of the EMS role in the Minnesota Mobile ECMO Program seems to be focused simply on identifying the right patients quickly and notifying the ECMO team. What else do you think EMS systems need to be focused on in order to be part of a successful cardiac arrest ECMO program?
Peterson: One is mechanical CPR. The data doesn’t necessarily show an advantage or survival benefit to using those devices, but here in the Twin Cities we think they’re essential. In part because you can’t do adequate CPR in the back of a moving ambulance. And if you’re not going to do good CPR during those 10 minutes it takes to get to the hospital, you might as well just leave them on scene and pronounce them dead. So even though the data doesn’t say there’s a survival benefit exclusively for mechanical CPR, it has to be part of the bundle of care for getting the patient on ECMO. I would say if you don’t have mechanical CPR, ECMO isn’t even an option.
Another thing is really the training, and starting to deconstruct the ACLS algorithms and treat the VFib as a potentially reversible cause of cardiac arrest and load and go. We’re even thinking now that some PEA patients that have a non-cardiac cause may benefit from this, whether it’s using ECMO or, you know, ultrasound is the next big thing. If you have PEA with zero cardiac activity, that’s not necessarily reversible. But if you have somebody with a GI bleed, or profoundly hypotensive, and you can’t get a pulse but you see some cardiac activity on ultrasound, that might become a load and go cardiac arrest.
It’s going to take training and recognition by EMS clinicians of what they can do, and what the hospital can do, and trying to breakdown some of that pride and arrogance to say, yes, you’re a paramedic, but that doesn’t mean you can cure everything. There are still some things that only hospitals or physicians can do and you can’t. And to recognize that we’re all partners here, working toward the same goal of improving the quality of care and saving lives.
A lot of that comes from the medical directors. I think we do a pretty good job of engaging with our crews, we respect them and they respect us, so it’s not an us-versus-them thing. We can tell them they need to get these patients to the hospital, and they don’t see that as an insult, they see it as the right thing to do for the patient. It’s the same thing that we, as emergency physicians, go through when we recognize that many heart attack victims don’t need the ER, they need the ECMO team and the cath lab.
The other big thing is feedback. These crews can’t just be taking these ECMO candidates to hospitals that you never hear from again. We’ve really worked hard to provide feedback, to let medics know what happened with the patient after cannulation, and to tell them that what they did actually made a difference and saved a life.