As improbable resurrections go, the revival of Game of Thrones' Jon Snow, after being stabbed to death by a mutinous faction of his own men, ranks as only slightly more miraculous than the recovery of a 59-year-old man who came to San Diego's Sharp Memorial Hospital emergency department in full cardiac arrest in 2011.
Ralph Berry had suffered a massive out-of-hospital heart attack. He was awake and talking when the emergency personnel picked him up, holding his chest and describing his pain. A field ECG confirmed that he was having a STEMI. He waved goodbye to his wife as he was loaded into the ambulance, but on the way to the hospital, he went into ventricular fibrillation and failed to respond to resuscitative measures. “Sharp, be aware your patient just coded,” the medics radioed before they arrived.
“EMS had tried everything to get him back, and they just couldn't do it,” recalled emergency physician Zack Shinar, MD, who had no more success than EMS. He said he “threw every drug in the code box” at his patient, along with an uncountable number of shocks. At this point, in most circumstances, Mr. Berry would have been pronounced dead. But this wasn't “most circumstances.” Dr. Shinar, an EP at Sharp and faculty for the University of California at San Diego's Emergency Medicine Residency, and a colleague, Joseph Bellezzo, MD, had recently been talking with cardiothoracic surgeon Walter Dembitsky, MD, about some frustrating cases in which they had lost patients, and they were ready to try something radical.
“I'll never forget this woman in her 50s who had a pulmonary embolism,” said Dr. Bellezzo, the vice chair of emergency medicine, the ultrasound director, and the Sharp ED ECLS director. “Her BP was fine, and then it started to slowly drop. We gave her tPA, max pressors, everything. But over a matter of hours, she died very slowly and painfully in front of me. It was horrible.”
The next day, Dr. Bellezzo bumped into Dr. Dembitsky and told him the patient's story. “Why didn't you try ECMO? We use it upstairs all the time,” the cardiothoracic surgeon said. Extracorporeal membrane oxygenation is relatively common before and after cardiac surgery but not in most U.S. emergency departments. Putting an arresting patient on cardiac and respiratory support via ECMO, he suggested, could buy the emergency physicians time to address the problem that caused the arrest in the first place — or get the patient transferred to a service that could do so, like the coronary cath lab.
“Do you think we could do it in the ED?” Dr. Bellezzo asked. Dr. Dembitsky said yes. “He walked me upstairs and showed me the machine, which is very portable. The equipment used to hook the patient up to ECMO is fairly invasive, but he convinced me that it was something emergency physicians could learn.”
Nothing to Lose
And then Ralph Berry was rushed into the Sharp ED, dying despite every resuscitative effort. Figuring that there was nothing to lose, Dr. Shinar called Dr. Bellezzo. “I'm going to run the code, and you're going to put him on ECMO,” he declared. “We had no idea how to do this, but he was going to die if we didn't.”
Fortunately, the 24-7 ECMO team summoned to the emergency department — two nurses cross-trained in ECMO — included one nurse who served as a lead for the hospital's ECMO program, with decades of experience and education. When she asked Dr. Bellezzo, “What size femoral cannula do you want?” he responded, “You tell me!”
They began the difficult process of cannulation of the femoral artery and vein, and then hooked up Mr. Berry to the machine. Five liters of blood flow per minute began flowing through the pump — and then, the entire femoral artery section exploded. “There was blood everywhere. All over the walls,” said Dr. Bellezzo. We now know that we should have confirmed where the lines were before starting the machine up; it turns out that the venous section went in fine, but the arterial cannula got backlogged in the soft tissue.”
Dr. Bellezzo and Dr. Shinar were dejected. “At least we gave him a shot,” they were telling each other when the chief of the hospital's trauma service, Frank Kennedy, MD, walked by. “Is this a trauma?” he asked, staring at the bloody walls.
The emergency physicians figured they should at least try to learn how to do the process better next time. They explained to Dr. Kennedy what they were doing, and asked him to do a cutdown of the patient's femoral artery. “He finds it, pokes a hole in it, and we start passing in the wire and handing him the dilators. He puts in a 19 French arterial line under direct visualization,” Dr. Bellezzo said. Mr. Berry had been undergoing CPR for 65 minutes. “At that point, we thought, ‘What's the harm; let's put him on bypass.’”
This time, everything worked fine, although Mr. Berry was still in v-fib. The team transferred him to the ICU, still expecting that he would not live. “Nobody survives 65 minutes of CPR,” said Dr. Bellezzo. “Zack and I are walking downstairs, totally discouraged. Then I get a call from the ICU doc. ‘This guy's moving up here!’”
Dr. Shinar and Dr. Bellezzo raced back to the ICU to find that their patient was moving his arm. Mr. Berry would later tell them that he had been trying to look at his watch to tell his wife that it was late and she should go home because he was OK.”
He wasn't, of course — not yet. He had brain activity and pulses back, but was still having a massive STEMI. But nine days after a stent was placed to open up the 100% occlusion in his left anterior descending coronary artery, Mr. Berry walked out of the hospital, fully neurologically intact. “He refused a wheelchair and walked out shaking everybody's hand,” marveled Dr. Bellezzo.
Was Ralph Berry an anomaly? Drs. Bellezzo and Shinar didn't think so. Over the next year, they developed a protocol for which patients should be considered for Extracorporeal Life Support (ECLS). Patients must undergo 100 percent advanced cardiac life support by usual protocols. While this is happening, cannulas can be put in and the ECMO circuit set up. “We wait until we get to the point where, in most situations, the patients would be declared dead,” said Dr. Shinar. “Then we put them on bypass. If they still don't survive, they would not have survived anyway. Any win is a 100-percent win.”
Dr. Shinar, Dr. Bellezzo, and colleagues reported on their first year of experience on eight patients; five of them survived and left the hospital neurologically intact. (Resuscitation 2012;83:966.) Eighteen patients met the criteria, but 10 did not start bypass because their clinical conditions improved or resuscitative efforts were terminated. “Those are five people who would not be alive right now,” Dr. Bellezzo said.
Since then, the Sharp team has traveled to multiple conferences, presenting their protocols and sharing their experiences; Mr. Berry frequently joins them. They have performed ECLS on about 30 patients over the past five years, Dr. Shinar said. “Our rate of patients who walk out of the hospital neurologically intact after ECLS ranges between 22 percent and 30 percent.” Compare that with the well-known out-of-hospital cardiac arrest survival rate of around eight percent. A 2013 study found that survival rates could be even higher among certain patients. ECLS more than triples neurologically favorable survival in witnessed out-of-hospital cardiac arrest of cardiac origin (29% vs. 8.9%). (Crit Care Med 2013;41:1186.)
The experience at Sharp Memorial was enough to make a believer out of Scott Weingart, MD, now the chief of emergency critical care at Stony Brook Hospital in New York. After interviewing Drs. Bellezzo and Shinar for his EMCrit podcast in 2013, Dr. Weingart told his wife, “I was just on a phone call that's going to ruin my life. I couldn't accept that these guys were doing it, and I wasn't.”
Dr. Weingart was so convinced that he took a year off to pursue an ECMO fellowship, after which he accepted his position at Stony Brook, in part because it had CT surgery and an ECMO program. “We've done our first few cases and have had good results,” he said. “I feel like this is the future of resuscitation.”
Is ECLS Right for You?
Not every emergency department has the capabilities to institute ECLS, however. “We can teach people the physiology and the mechanics behind it easily, but getting it into specific hospitals is potentially more difficult,” Dr. Shinar said. If you're contemplating ECLS in your ED, ask yourself the following questions:
- Do we have a true, formal heart program? If so, you probably already have an ECMO team above you waiting for a heart patient to crash that can be easily mobilized to do the same thing in the ED. If not, instituting ECLS in your ED may be difficult.
- Is our cath lab program ready to deal with the hit to its mortality rates? The American College of Cardiology's cath lab metrics are based on 30-day mortality rates, and don't carve out patients who were in arrest and on ECMO before they were transferred. “Even with our best statistics, 70 percent of the ECLS patients are still going to die, and that's going to grossly impact your mortality rates,” Dr. Bellezzo noted. “Our hospital has the best interventional cardiologists, but we have a higher cath lab mortality rate than any other hospital in the community, and this is why: We're sending them our super-high-risk ECMO patients.”
- Can we get support from other departments and hospital leadership? “You need to start making friends upstairs with the cardiothoracic surgery team, with intensivists, and the administration,” Dr Bellezzo said.
The cost of initiating an ED ECMO program is not seriously prohibitive, Dr. Weingart said. “Per patient, it's maybe $1,000 for the cannulas and $1,500 for the circuit, and then the rest is already sunk costs. The machine's already bought by your hospital; you won't be buying it de novo,” he explained. “The ICU costs, well, if the patient survives he is going to the ICU post-arrest no matter what. So you can initiate ECLS for $2,500 in actual supplies.”
What about the concern by grieving families that patients will be maintained on a pump past the point when they have a chance of neurological recovery? “Any center that's successful with an ECMO program for out-of-hospital arrest has to have an understanding that this is not a clear give-and-take between the family and the doctor,” warned Dr. Weingart. “After a few days, if there is not a good chance of neurologic viability, the doctor has to say that he is withdrawing ECMO, not ask the family if they want you to withdraw ECMO. This is not a system that was ever meant to be used for an extended period of time, and if you can't make those calls, you shouldn't be doing ED ECMO.”
The development of ECLS in the ED also poses some dilemmas when it comes to emergency transport, Dr. Weingart added. “In general, the EMS world has changed to a stay-and-play modality. Chest compressions, epinephrine, and defibrillation if necessary can all happen in the field, rather than putting personnel at risk driving with lights and sirens. But this modality hurts any kind of advanced resuscitative technique such as ECMO. We tend to not get some of the patients we think we should get. It's a work in progress everywhere.”
ERECT (Extracorporeal REsuscitation ConsorTium) is a collaborative of U.S. centers involved in the active performance of Emergency Department Extracorporeal Membrane Oxygenation (ED ECMO), seeking to drive best practices. To date, seven centers are involved in ERECT — besides Sharp and Stony Brook, they include the University of Chicago, the University of Michigan, the University of Pennsylvania, the University of Utah, and Jefferson University Hospitals. Find out more about ED ECMO at www.edecmo.org or on ERECT's site at www.erectcollaborative.org.
“Five years ago, people said we were crazy, that it was a random goofball thing that happened in San Diego,” Dr. Shinar said. “But we're hitting critical mass now. We've had three saves this year at a hospital in Canada that we trained. The University of Utah has had several saves just within the past nine months. ED ECMO is just a part of the spectrum, of course. It has a lot of limitations and complexities. But it's a stepping stone for us to look at resuscitation less nihilistically. We can't accept eight percent anymore.”
Sharp Memorial Hospital Protocol for ED ECMO
- Persistent cardiopulmonary arrest despite traditional resuscitative efforts
- Shock (SBP<70 mm Hg) refractory to standard therapies
- Initial rhythm asystole
- Chest compressions not initiated within 10 min of arrest (either bystander or EMS)
- Estimated EMS transport time >10 min
- Total arrest time >60 min
- Suspicion of shock from sepsis or hemorrhage
- Pre-existing severe neurological disease prior to arrest, including traumatic brain injury, stroke, or severe dementia
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