ECMO truck

[Aprz]

I'd also be concerned that once this truck goes into operation, crews will stay and play more on scene instead of rapidly transporting to the ER.

For most cardiac arrests, that would actually be a good thing. Some patients benefit from rapid transport, but generally cardiac arrest is just ACLS that can be done in the field. Trying to transport them tends to interrupt compressions moving them on a scoop, loading and unloading from the ambulance, and I've heard dozens of studies for both adults and pediatric patients saying chest compression qaulity dramatic decrease during transport. It's honestly a bad idea to scoop and go with modt cardiac arrest calls.

 

[Peak]

Certainly cheaper in terms of fixed costs, I'd wager. Does ED ECMO involve meaningfully more staffing?

Most programs I know of have the ICU manage ECMO once surgery and perfusion set it up until they get up to the unit.

 

[Peak]

For most cardiac arrests, that would actually be a good thing. Some patients benefit from rapid transport, but generally cardiac arrest is just ACLS that can be done in the field. Trying to transport them tends to interrupt compressions moving them on a scoop, loading and unloading from the ambulance, and I've heard dozens of studies for both adults and pediatric patients saying chest compression qaulity dramatic decrease during transport. It's honestly a bad idea to scoop and go with modt cardiac arrest calls.

Once you start VA ECMO you shouldn’t be doing compressions anymore

 

[Aprz]

Once you start VA ECMO you shouldn’t be doing compressions anymore

I don't know anything about ECMO other than the gist. To clarify, I was under the impression they were talking about crews waiting on scene BEFORE ECMO shows up instead of scoop and go.

 

[EpiEMS]

As I go through the literature, I'm slightly more optimistic that prehospital ECMO is going to deliver the outcomes we're hoping for. To quote the authors of a prospective analysis from Paris that included analysis of both in-hospital and pre-hospital ECMO published in the past year:

Among patients treated with extracorporeal-CPR, 8.4% was discharged alive, compared with 8.6% in the conventional-CPR group. The neurological outcome was favourable in 84% of extracorporeal CPR and 96% of conventional-CPR survivors. Among patients who died, organ donation was more common in the extracorporeal-CPR than in the conventional-CPR group. Similarly, another study found that brain death was more common after extracorporeal-CPR than after conventional-CPR.

But...

After adjustment, three factors were independently associated with hospital survival, namely, initial shockable rhythm (OR, 3.9; 95% CI = 1.5–10.3; P = 0.005), transient ROSC during initial resuscitation (OR, 2.3; 95% CI = 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI = 1.5–5.9; P = 0.002).

In the absence of an RCT, hard to conclusively state that prehospital ECMO is doing anything so exciting for the patient, but maybe this is something.

 

[Tigger]

The resuscitation consortium has been operating a "mobile ECMO team" that responds to outlying hospitals to provide care at non-ECMO facilities and then facilitate the transfer back to the home institution. It was my understanding that they brought all their own equipment and staff and then used someone's CCT program to assist with transfer. The last article I read about the "ambulance" was prior to it being built and one of the program managers stated (or I interpreted) that their new intention was to make providing out of institution ECMO easier by bringing their own suite to a hospital, and not really the field.

 

[Peak]

The resuscitation consortium has been operating a "mobile ECMO team" that responds to outlying hospitals to provide care at non-ECMO facilities and then facilitate the transfer back to the home institution. It was my understanding that they brought all their own equipment and staff and then used someone's CCT program to assist with transfer. The last article I read about the "ambulance" was prior to it being built and one of the program managers stated (or I interpreted) that their new intention was to make providing out of institution ECMO easier by bringing their own suite to a hospital, and not really the field.

I think the challenge to that is that when patients are so unstable that we consider ECMO they are likely tanking their saturations or BP with something as simple as a turn or suction despite maximized or near maximized medical management. I don’t think that moving a patient out to the truck for cannulation is a great idea, and honestly if they can tolerate that movement well they can probably tolerate the drive across town.

There is also the matter of trying to have the most sterile environment possible. I doubt that the back of any truck is going to be more sterile than most ICU rooms, let alone a positive flow or laminar flow room.

 

[VFlutter]

I think the challenge to that is that when patients are so unstable that we consider ECMO they are likely tanking their saturations or BP with something as simple as a turn or suction despite maximized or near maximized medical management. I don’t think that moving a patient out to the truck for cannulation is a great idea, and honestly if they can tolerate that movement well they can probably tolerate the drive across town.

There is also the matter of trying to have the most sterile environment possible. I doubt that the back of any truck is going to be more sterile than most ICU rooms, let alone a positive flow or laminar flow room.

I think there are two different things being discussed. There are programs that are doing true pre-hospital ECLS cannulations and then there is what Tigger is describing as what some call "ECMO Retrieval" in which the ambulance is just a means to get the ECMO team and equipment to an non-ECMO capable hospital, cannulate, and then transport the patient back to the ECMO facility. The cannulation is still performed at the bedside in the ICU or in the OR/CCL just like would normally be done, they aren't taken to the ambulance for cannulation.

Occasionally we will pick up a CT surgeon with equipment, fly them to an outlying hospital to cannulate, and then transport back. This doesn't happen as much anymore since now more hospitals are capable of initiating ECMO to stabilize and transport even though they can not keep and manage the patient.