ECMO

[00:00:21] Matt: ECMO. Let’s talk about ECMO.

[00:00:23] Erik: No, I got some questions. I want to ask you a question.

[00:00:25] Matt: Oh, you got questions?

[00:00:26] Erik: Okay. Well we gotta lead into it, oh, okay. But I’m just curious, do you know what the three most deadly diseases are?

[00:00:32] Matt: Three most deadly. Now are we talking like,

[00:00:35] Erik: plus, I was reading about is that 10 most deadly diseases?

[00:00:41] Matt: Like are we talking about heart disease?

[00:00:43] Erik: That’s number one. Yeah. Oh, okay. The heart disease is by far, number one. I mean, it’s like you add up all the traumas and cancers, it won’t even equal that and Whataburger, so what’s, so that’s number one. Okay. The number one greatest killer. What’s, and, and heart disease.

It’s a trick question. So number two is stroke, but they consider that a cardiovascular disease. I was wondering, so that’s together. So number one and two are kind of, you know, kissing cousins. Is that the right

[00:01:06] Matt: term? Sure. In, nevermind. I’m not gonna say Kentucky. I was gonna say Kentucky too. That’s so

[00:01:13] Erik: bad.

I got a sister that lives in Kentucky, so I feel like I can say I love Kentucky.

[00:01:16] Matt: Love. I’ve been to Kentucky. It’s a beautiful place. Yeah. Number three is trauma. I don’t know. No, no. I thought maybe they’d lose trauma as a disease cause Well, cuz those

[00:01:23] Erik: are both, both stroke and heart disease or cardiovascular diseases.

Number three surprised me. Mm-hmm. And I haven’t verified the data, but it lower respiratory infections. Pneumonias and things like that. Oh, okay.

[00:01:34] Matt: Yeah. Yeah. That’s the number three. Well, you think about older people, nursing homes, they get pneumonia,

[00:01:38] Erik: but yeah. Okay. Yeah. So interesting. Now let’s, how do we get to ECMO from there?

Well, some of the most deadly diseases we treat that we can make a difference in, I think our cardiac arrest patients, we talked about this in our cardiac arrest lecture we did a couple weeks ago. Yep. The, the survival rate of outta hospital CPR or cardiac arrest is about 9.1% in adults. 11.4 in kids, I think we talked about.

Yep. Yep. Out of hospital. In hospital. Different game. Yeah. But out of hospital where we work less than 10% of our patients are surviving. And so, That’s, that’s, we’ll get to ECMO because I think ECMO is so exciting because now we can take this patient demographic, a portion of them, we’ll talk about it.

Yes. Yeah. And we can save a whole lot of lives. Mm-hmm. By using this technology. It’s amazing technology, ECMO and we really, it’s been around a long

[00:02:31] Matt: time now. It’s since the nineties, right? Yeah, yeah. They’ve been using our little kids. Yeah. Around.

[00:02:36] Erik: I know when, when I was back, when the earth was young and in my training we were using ECMO for little babies with cardiac abnormalities where we had to bypass the, the circulation in the lungs to, you know, fix the transplant or whatever we had to do.

[00:02:52] Matt: It was a lifesaving. Piece of Machines amazing what it does. Yeah, yeah. It’s a simple machine from what I understand, but I mean Yep. Small, portable, they use it in helicopters. We talked to a flight nurse and she said it’s really neat to watch.

[00:03:02] Erik: ECMO, you know, extra corporal which means outside the body, right.

Membrane oxygenation. Membrane oxygenation. So basically what you’re doing is you’re bypassing your lungs in your heart. Yep. And the machinery is, is, is oxygenating the blood and pulling the CO2 out and adding the oxygen Yep. And reheating it too. Yeah. And there’s a bit of heat component to it and, and putting it back into the body and that gives the lungs and the heart a chance to recuperate or do whatever you need to do.

Yep. While you maintain oxygenation of other vital organs like your brain. Yeah. Specifically. Yeah. Yeah. So that’s, that’s what ECMO is. And I don’t think we need to jump in and geek out on that. No, I think

[00:03:40] Matt: we’re gonna have some other parts where we’re gonna bring in some people Yeah. And talk to some experts.

[00:03:43] Erik: Yeah. This is part one, kind of an introductory thing

[00:03:46] Matt: Yeah. But I think this one we were gonna talk a little bit about, not a little bit about, but mainly focus on as cuz our audience pre-hospital Yeah. Is mostly pre-hospital providers. Mm-hmm. And how does this change. What we do in the field because it

[00:03:59] Erik: doesn’t whether, I mean the, the little intricacies of how ECMO works may That’s cool.

Yeah. And it’s fun to geek out on that stuff. Exactly. It doesn’t really matter to us.

[00:04:06] Matt: Yeah. because we’re not. Now I will say that the, the, we recently started doing ECMO in my department and we’ve had one crew and I mean really recently started doing it. And one, we’ve had one crew take a patient down there and they said it was what was really neat.

And what I think is really neat, and maybe we could talk about this, is. Is how much more accepted the pre-hospital providers are becoming by the hospital providers. You know, back when I started as an E M T paramedic, the nurses didn’t really care for us much. They, they didn’t re a lot of, I think a lot of older generation nurses, maybe even physicians, didn’t really see EMTs and paramedics as real providers.

Right. And now they’re realizing the dramatic impact that we have on the. The healthcare system as a whole, and they’re like, they’re, we’re doing a lot of really good things that doesn’t get you excited. Yeah. Have a massive impact on patient outcomes, massive impact. Uhhuh, I think ECMO is a, is another new part of that.

Yep. And so when this crew specifically got down to this facility, They made that crew part of the ECMO team when they got there and they were helping them do stuff, they still had them on their Lucas device and it was really neat. It’s really been a neat thing to, to experience.

[00:05:23] Erik: I think it’d be worth briefly discussing some of what now I, I know we’ve been using ECMO a long time, but I think what was really brought ECMO to.

The forefront was covid. Yeah, for sure. I think, and you know, when you get covid, we’re not gonna dig deep into this, but you, you’re really just shooting your lungs to hell. Right. That’s really what you’re doing. Right. And it’s not the covid virus, the coronavirus or the, you know, whatever. It’s a, it’s, that’s what it is.

It’s a coronavirus. Yep. Yeah. It’s not the virus that really causes the problems. Your body’s inflammatory response to it, and the fight that happens to, to kill it. Anaphylaxis. Right. It binds to the pneumocytes. Yeah. And, and, and when, and that’s where the battle takes place. And, and we destroy our lung tissue.

And remember we talked about this in previous lectures. It’s a, our lung tissue, if you’ve laid out all those alveoli flat, and it’d be the surface area of a tennis court, one cell thick. Yep. And underneath that cell thick membrane would be 6,500 kilometers of tiny little blood vessels exchanging gases through.

I mean, it’s just an amazing interface. So an amazing organ. Right. And we talked about this on our, our, our sea lectures. Right. Phenomenal. I mean, it’s just amazing pathophysiology. It’s incredible. Yeah. But the point is, is that when Covid would destroy the lung tissue of the vast majority of folks on the ventilator, We’re, we’re dying, right.

Because of the bar trauma, the ventilator and the diseased lung organs the, the, the alveoli that were diseased. Mm-hmm. And, and munched up. And so by putting folks on ECMO, you bypass the lungs, let them heal Yep. While you’re, you’re using the ECMO to oxygenate Right. And, you know, remove the carbon dioxide from the blood and you’re able to give the lungs a break.

Yep. Yep. And the heartbreak too, I suppose. Yeah. You can look at it that way as well. And because that’s the benefit in cardiac arrest, right? Same thing, same sort of philosophy. Yep. Usually what kills people in, well, let me say, why do people go into cardiac arrest, medical cardiac arrest? What is the, the, usually what’s going on?

Pump problem. Use the pump problem. Yeah. And so usually the pump is diseased and it needs to be fixed. And somebody in cardiac arrest. You know, we’re only surviving. Only about 9.1% of these folks are surviving without a hospital cardiac arrest. When you grab the right patients mm-hmm. And you select them and you put them on ECMO, fix the Heart and these folks are, are, are leaving the hospital

[00:07:44] Matt: neurologically intact, neurologically

[00:07:45] Erik: intact at a much higher rate Yep.

Than 50%. Well that’s the

[00:07:51] Matt: current right. Current’s Right. Is saying 50% or

[00:07:54] Erik: better. Right. And, and ECMO doesn’t mean you’re gonna live. It’s just Right. I, what I was reading today an article that came out in gems it. It looks like about 50% survival rate when you’re on ECMO. So half the people die on ECMO.

Right. But when you’re looking at what’s less than 10% survival.

[00:08:10] Matt: Yeah, exactly. Now if that’s you or somebody you love mm-hmm. I’m taking those odds all day long. Right? Yeah.

[00:08:16] Erik: Right. So I think that’s significant. That’s exciting.

[00:08:19] Matt: It is exciting. And I think we should be excited, as you know, as as first responders, as firefighters, ems, you know our number one job in the fire service is to save lives.

Yep. That, that is our number one job over, you know, property. All that other stuff is secondary to saving people’s lives. And, you know, that’s not just from fires, that’s not just from car accidents. Mm-hmm. I, I would say with, I know for a fact that I have had a greater impact working in people’s lives.

As a paramedic, then I have a firefighter. Mm-hmm. I have, I can remember one fire that I have been on where somebody was pulled out of a burning building. One in 18 plus years. I’ve had numerous numerous in my department, numerous CPR saves numerous people have come back from kids all the way to older people, you know.

So if that’s our goal, we should be super excited about ECMO and what’s our role in ECMO. Mm-hmm. And, It, it’s not really, it does change how we work cprs. And there’s lots of things, like you were talking about, there’s lots of reasons why somebody gets put on ECMO, respiratory problems, covid, things of that nature.

But we’re specifically talking pre-hospital leave with the CPR patient, right. The cardiac arrest patient. Mm-hmm. That, and to qualify, we’re not talking about the 90 year old male in a nursing home that’s had a stroke and has no quality of life. That’s not a patient in ECMO in, in my department. We did.

We studied it when we launched it, and in 2022 we had 152 cardiac arrests, uhhuh throughout my city. And we looked and only 12 of those patients would’ve met the ECMO criteria. Yep. And there’s a lot of different criteria out there. You have one here. And

[00:10:05] Erik: I’m, and I don’t think this is, this is from on the east coast.

Yeah. But and, and we’re here in Texas Yep. And in California. I mean, things are gonna be a little bit different, but I think the basic stuff, from what I can tell, is pretty, pretty pretty consistent. Yes. I mean, it’s, it’s gotta be a witness age range. Yes. Yeah. Witness arrest, cardiac arrest. Yep. Yep. Bystander.

C P R.

[00:10:24] Matt: Yeah. Ours is within five

[00:10:25] Erik: minutes. Yeah. So what is, why would they include that? Well, I, I think it’s, it’s pretty obvious, we’ve talked about this in our cardiac arrest lectures. When you have bystander cpr and you start that early Yep. You decrease that slope of death. We, you know? Yep. Yep. And, and it improves survival.

[00:10:40] Matt: It keeps that brain perfused. Yep. Which again, ultimately, We’re gonna get the heart beating again. But if the brain’s dead, then what’s the point? Yes. You start that circulation early, you’re keeping that brain perfused. You’re buying time, but

[00:10:52] Erik: there’s a chance, right. Always a chance. So we should always do ECMO, right?

With every cardiac arrest. Yeah. Well,

[00:10:57] Matt: why don’t we do that? Well, the problem is we actually were looking at launching ECMO prior to Covid. But then Covid hit and every ECMO machine in the country was being used. Mm-hmm. And there was waiting list to get on ECMO limited resources. And so yeah. There’s not a ton of ECMO facilities.

There’s not a to a ton of, there’s not an unlimited amount. I mean, heck, we were running out of ventilators during Covid. Yep. You know, if you put every single person on ECMO. And two, like I was listening to a, a podcast about ECMO and it was talking to a, a, a physician that does this. And the other side of it too is that you don’t want to put a patient.

That isn’t going to live past ECMO on ECMO. Right? Because they were saying that it’s very difficult. You have grandma or grandpa that you put on ECMO and you know, now grandma and grandpa are awake and the family’s thinking, oh, this is fantastic. And you have to now go in and explain to the family that the only reason why they’re awake is because they’re on ECMO.

And the minute we take ’em off, they’re not gonna live out. So yeah, not everybody needs to be on it.

[00:11:53] Erik: And it, I think when you look at the data, the survival rates are X, Y, Z, and, and we’re not gonna be talking about a lot of that now. Yeah. But when you get over a certain age, yeah. The, the, the utility of putting somebody on ECMO.

So it’s a real fluid, sort of a criteria that different agencies will employ. Only because in certain communities there may only be X number of ECMO. Right. You know? Facilities, opportunities, facilities. Yeah. Whereas in maybe some other metropolitan areas, like, you know, here we are in Dallas, we’ve got fourth largest metroplex in the country.

We’ve got multiple sites that are doing ECMO. Right. So maybe we can handle more. When you look from a population health perspective, what is the chance of somebody going into cardiac arrest and, and which of these patients would be viable? Right. We may be able to capture a larger portion. Yeah. Which would impact what our criteria.

Would be, so that’s kind of why we’re not getting into the details of the criteria, but, but the criteria will usually relate to survivability. Mm-hmm. Which is gonna relate to. Was it witnessed cardiac arrest? Was there bystander? Cpr? Yep. And we obviously, we talked a little bit about being in an initial shockable rhythm.

Mm-hmm. P greater than rate of x, y and zm, the twenties, what I use in our protocols, but Yep. And then age is another thing.

[00:13:10] Matt: Yeah. And a lot of the age is, is kind of subjective. I know they were telling us about a case. At a local city here where the patient was, I want to say he was like 72 or 73 years old, but he was a very fit 72, 73.

Mm-hmm. Went to his gym like he did every morning, was on the treadmill and collapsed. Yeah. The gym staff recognized that, obviously recognized witness collapsed. Yeah. So it was witnessed. Yeah. They immediately, they were all CPR trained. Uhhuh, they recognized he was in cardiac arrest. They immediately be began compressions.

The crew got there. The firefighters, and this is kind of what we’re gonna address today, is what do we need to be looking for? They recognize, geez, this guy’s a little bit outside of the age range, but they wouldn’t have looked at this guy and thought he was 73 years old. He looked very fit because he kept himself in shape.

They all the other factors were in place. They called the ECMO team. They said, Hey, this is what we got. They said, bring them. We’ll try it. Yeah, they brought the guy there. All the other indicators were there. That guy walked outta the hospital. Neurologically intact. Like a week later. There was

[00:14:15] Erik: another case, a 46 year old patient was not witnessed, but because of his age.

And because of the way he appeared, they decided, let’s go for it. Give it a shot, walked out of the hospital. Yep.

[00:14:25] Matt: So it’s, it’s, it’s really neat. Yep. And like you said, there’s a lot of that inclusion criteria. Is there, is there any more that you

[00:14:31] Erik: willing to Well, a couple other things. I mean you mentioned living independently, that’s a factor.

Going to a nursing home for Yeah. A 90 year old who’s bedridden. Yeah. I mean, it’s not that that life is less valuable. No. It’s just that the chances of survival are so low. That utilizing the resource of ECMO it’s a limited thing. You, you want to have the highest chance of survival. It’s almost like triage,

[00:14:53] Matt: right?

Yeah. It’s post ECMO. Is this patient gonna have a quality of life? ECMO is not a forever solution. It’s a bridge to a transplant. It’s a bridge to recover, putting in a cath or whatever. And is that person gonna have a quality of life afterwards, even if you had a 50 year old mm-hmm. That maybe suffered a stroke or had a massive head trauma.

Yep. And has no quality of life is on a ventilator. Like that person doesn’t have the reserves to survive a cardiac arrest and you put ’em on ECMO. So you, they have to be selective of who they put it on. But that is very subjective. Yeah. Like I say, you might have a 75 year old that really meets the criteria and a 50 year old that doesn’t because of their comorbidities and so on.

And you

[00:15:34] Erik: could have a 22 year old that meets criteria that you know, depending upon the, the region you’re in. Yeah. May not meet criti. I mean, it, it, it’s there, there’s a little bit of I guess wiggle room,

[00:15:45] Matt: subjectivity. Yeah. Yeah. To the, to the

[00:15:47] Erik: criter. And in this particular agency, they would communicate with the facility.

And even discuss it with the physician. Yeah. Potentially within the first 10 minutes. That’s

[00:15:58] Matt: what they, okay. Yeah. So everybody’s a little bit different in how they do it. Yeah. So ours, we have an inclusion criteria, and I think it’s important that we talk about how does this change our response as pre-hospital providers.

Yeah. Because for years we have been, you know, really hammering on stop rushing to the ambulance in a cardiac arrest situation. Yeah. Yeah. We’ve been talking about this, especially like PD patients. Mm-hmm. From dose of diesel. Right? Well, in this situation, we want timely dose of diesel is what they need.

Because there is a, a window, a timeframe. Yep. That’s anywhere from 30 to 45 minutes, 30 minutes

[00:16:33] Erik: here. Yeah. And I think 45.

[00:16:34] Matt: 45 for us. So it, it depends on, on, you know, whatever each individual inclusion criteria is. But there is a time window. Yep. And we have to abide by that. And so we can’t spend. 20 minutes on scene, working a code.

If I have a 20 minute transport time, that’s not gonna work. Not gonna work. So we have to, as pre-hospital providers, we have to be thinking about this when we get toned out to A C P R. We’ve gotta have ECMO on our brain. And when we get in the ambulance and we’re looking at the notes, We have to be thinking just based on the notes.

Okay. Am I going to an assisted living facility? A nursing home? Don’t worry about ECMO. The, the ECMO is probably not gonna, probably not gonna be a camp. Yeah. Probably not gonna be a candidate. Right. Is the patient 90 years old? You know? Mm-hmm. Are they, you know, of an extreme age? Does it say that they’re a cancer patient or something like that?

Or is it saying 55 year old male wife called husband just collapsed? Yep. Oh, okay. Interesting. So the call that we actually had in my department was It actually came in as a seizure call was what they originally got called to. And right before they arrived on scene, they were notified by dispatch that it was now a CPR in progress.

Luckily there was a very alert paramedic on scene that when he got in, recognized the patient was very young and all the other started realizing that all the other indicators were there and quickly made that assessment. And so that, I think is the biggest thing for us as pre-hospital providers, is if you’re a medic on the box mm-hmm.

You’re looking at your notes. You’re keeping ECMO in your mind, like you said. Yep. If we’re going to a nursing home, probably not an ECMO candidate. Looking at the age, oh, 55, 50 year old male, 60 year old male collapsed staff at the nursing home staff. At the nursing home maybe, yeah. This might be an ECMO candidate then.

My priority when I’m getting on scene as the medic is, is my painting, is my patient meeting that criteria? Yeah. Are they in a shockable rhythm? Maybe the officers talking to the bystanders. Did someone witness the collapse? Did somebody get on the chest within five minutes, so on and so forth. Yeah. And then quickly making that determination.

Okay, hey, this is an ECMO candidate. Now what do I gotta do? Put in a superglottic airway. Mm-hmm. Throw on whatever kind of mechanical compression device you have. Lucas device or Pulse auto pulse, auto pulse, or whatever. Mm-hmm. Get ’em loaded up and start heading to the hospital. Now, a lot of that too will depend on.

You know, if you work in a major urban area, you might be only five minutes from an ECMO center, but I would assume that most people probably are gonna be a little bit further out. We’re 15 to 20 minutes probably from our, our closest ECMO center. So I’ve really gotta be cognizant about my time on scene, get there quick, and I gotta get there because that 30 minute or 45 minute is from the time the patient went down to when they arrive at that facility.

It’s not a, when we arrive on scene, you know, so we have to really be. Thinking about ECMO en route to the call once we get on scene and then we have to make that determination quickly and, and get

[00:19:33] Erik: moving. And it really makes sense that we optimize our on scene time with, with some of these situations.

Mm-hmm. In that we’re not doing anything they can’t do there. Right. But if we have a situation where they can do something we can’t do. You know, whether it’s like a trauma, blood products Yes, exactly. Or surgery with, you know, surgical emergency, whatever. Yeah. We gotta load and go. Yeah. And so this is one of those situations, we’re smart.

Yep. We can identify the situation, identify a potential candidate, load, and go.

[00:20:00] Matt: Now in Europe, they’ve been doing this for years in the field, these ECMO teams and surgeons. There’s a really neat picture when it was presented to us. I told you about this and I thought it was really cool. Of the ECMO team doing an ECMO procedure at the floor of the Louv.

I mean, it’s just like that. This picture is amazing to me. But yeah, they’ve been doing it in Europe for, for years in the field, and there’s places that have ECMO teams that are doing more mobile, and I think that’s gonna become more and more Yeah. Common. Yeah. Because it just does show real promise for having super high success rates.

You know,

[00:20:35] Erik: it’s just, if, if you could just step back for just a moment. And think about what’s going on here. You know, it wasn’t that long ago that we were treating sore throats with kerosene.

[00:20:45] Matt: Yeah. Or baldness with, what was it? SAP from a cherry treat.

[00:20:48] Erik: Yeah. A grapevine. Yeah. Whatever. But, but man, the, the, the me medicine in the last century has just exploded.

And the fact that we in the pre-hospital environment can identify patients that we can bypass their circulatory system. Yeah. And, and keep ’em alive and go from a 10% mortality rate all the way up to maybe even close to 50%. Yeah. I mean, that’s

[00:21:10] Matt: amazing. That is amazing. And you think about just in the last, what, 30, 40, 50 years that EMS has been around?

Yep. And we used to just be ambulance drivers and a taxi service. And now you look at the complicated things that we’re learning and doing in the field, finger thoracotomies and identifying ECMO. I mean, it’s amazing. It’s exciting. I find it exciting. It’s, it’s really neat. The, this ECMO thing is really neat to me.

[00:21:36] Erik: I think this should, this should get all of us excited. Yeah. This is,

[00:21:39] Matt: this is really cool. When you have that higher percentage of saving lives, that much higher percentage of saving a life, I think we should all be excited about that.

[00:21:45] Erik: Well, I think this was a good intro to ECMO. Yeah. And the physiology of sneezing and, and yawning.

Yawning. It was good. There’s good intro. So we talk about ECMO, we talk about what it is, you know, just surface level. Yeah. And

[00:21:59] Matt: our follow up, we’ll talk to some people, like I said, that do this and give us some more data and, and kind of see this a little bit more firsthand. Be cool.

[00:22:07] Erik: And if you’re listening to this and you, you know, I know we get a lot, I mean, all over the country.

Yeah. Our students. And you don’t have an ECMO program and you hear about it, get excited about it. Yep. Don’t be afraid, you know, this is just something that saves lives. Yep. And being part of the, I think we have a responsibility if, if there’s, if something we can do to improve mortality this significantly.

Absolutely. Something we need to get on board with for sure. Yeah, man, that’s great. Talk about this stuff. Yep. I’m looking forward to part two. This is really good. Yep. Cool.