In a perfect world, a patient suffering from cardiac arrest could get help for their heart without rushing into emergency surgery during an attack.
Or someone in critical need of a life-saving lung or heart transplant could wait days or weeks to find the perfect match.
Imagine a machine that could essentially breathe for a person with a severe case of H1N1 or COVID and allow their lungs time to recover on their own.
Nearly 350,000 people in the United States die from cardiac arrest each year, and fewer than one in 10 people survive a major attack even with CPR or defibrillators, according to the American Heart Association.
Could there be something that improves those odds?
Maybe so. Meet ECMO.
Extracorporeal membrane oxygenation, or ECMO, is a machine that essentially delivers hospitals, doctors and patients extra time and could change everything we know about surviving a heart or lung health crisis.
While ECMO is not new, its use in major hospitals in America has become more mainstream after H1N1 and COVID. Larger hospitals are investing in staff and the equipment that essentially serves as a bridge until a patient can heal on their own or get the treatment required to save their life.
In simple terms, ECMO can perform the work of the heart or lungs entirely outside the body. The machine supports your body while doctors work to manage or treat your condition.
Think of ECMO as a device that slows down time in a medical sense.
There are limits: ‘We just cannot offer to everyone’
If it sounds too good to be true, there is a downside. It requires 24/7 monitoring in an intensive care unit with an ECMO specialist sitting with you every minute of every day. It’s also not cheap with costs as high as seven figures.
In Virginia, its use is becoming more widespread in cities including Charlottesville, Richmond, Roanoke and Lynchburg as well as Northern Virginia. In more rural hospitals, a patient needing ECMO would likely be transferred to another hospital with a dedicated ECMO team.
UVA Health is a Level 1 trauma center and has the only adult ECMO team in Virginia named a Center of Excellence with platinum status from the Extracorporeal Life Support Organization.
“It’s still a very kind of resource-intensive therapy that we just cannot offer to everyone,” said Dr. Nicholas Teman, a cardiac surgeon at UVA Health who directs the adult ECMO unit. “There are limits to how many machines we have and how many ECMO specialists we have.”
In addition to the ECMO team, there are additional constraints with needing an ICU bed and ICU team.
As a result, there are strict criteria for who would be a good candidate for ECMO and who wouldn’t be, Teman said.
“If somebody has a terminal illness, and there’s really no kind of hope treating them in the long term, putting them on ECMO prolongs their life, prolongs their suffering, prolongs their death,” Teman told AFP. “That’s not good use of that therapy, because it doesn’t bring any benefit to that patient.”
During COVID, protocols had to be put in place to make sure the hospital was a good steward of the equipment and personnel.
“It’s not like a dialysis machine. It’s not like an antibiotic or a new hip or a new knee or a new heart valve … any of these things we can kind of take something else off the shelf and put it in,” Teman said. “It is a limited resource.”
UVA Health has 71 to 100 ECMO patients a year. While the number may seem insignificant compared to the number of heart- and lung-related deaths each year, those who had successful ECMO treatment know the extra time they received likely saved their life.
“I think it’s a very important therapy. It’s a very impactful therapy, a life-saving therapy, but it’s not for everybody,” Teman said.
What is the exit strategy? ‘We’re keeping them alive with this machine’
The other major player in the decision related to ECMO has to do with ethics. In rare cases, a person could end up on ECMO, and for one reason or another, there is no longer a path to recovery.
“We’re keeping them alive with this machine,” Teman said. “Anytime we make a decision to put someone in ECMO, the first question in my mind is do we have a pathway forward that they will be able to come off of ECMO?”
The exit strategy, as Teman refers to it, is the possibility of recovery of their heart or lung functions, a heart or lung transplant, open heart surgery to fix a valve or other problem or even a heart pump.
For example, if a patient has end-stage COPD or end-stage emphysema or is not a good candidate for a transplant, then putting them on ECMO is “not a good plan.”
“I personally try to err on the side of giving people a chance,” Teman said. “Even if I have somebody with other medical problems or social concerns that would preclude them from being a heart or lung transplant candidate, if we think there’s a chance that they’ll recover to where they don’t need the transplant and then they can come off the ECMO machine, I’m going to give them that chance.”
UVA Health has a process for what to do if someone is on ECMO with no chance to recover. They’ve never had to go all the way through it, thankfully, Teman said, and when it’s been close, the family has stepped in and made a decision before the hospital had to decide for them.
“We go to the ends of the earth to do what we can to save their loved ones, and when we come to them and say we’ve reached the point where we don’t think there’s any hope, we reach the point where we don’t think there’s any chance of survival, and we have nothing else to offer, usually the family says, ‘you’re right. We need to stop.’
“We have never gotten to the point, and I would hope we never have to get to the point where we are against the wishes of the family, forcibly withdrawing care and support of a patient knowing they’re going to pass away.
“That doesn’t make me feel good. That’s not why I went into medicine. That’s not why I do what I do,” he said. “I do this because of all the saves and all the people whose lives I think that we’ve saved over the years with this therapy.”
Should ECMO be used more?
The more people talk about ECMO and the more recognition it gets, the more likely it is to increase the utilization of the treatment, Teman said.
“There’s still a lot of folks that don’t have a lot of experience with it, and one of the things I’ve done since I’ve been here is kind of what I call a traveling roadshow. I have gone to various departments and groups and given lectures to faculty, given lectures to the residents, and try to increase the overall kind of understand of what ECMO is, but more importantly, when to call us and who’s an appropriate candidate for ECMO.”
He’s said he’s done additional outreach talking with surgeons and pulmonologists and intensivists to educate them and answer their questions about ECMO.
He’s also had other hospitals call him and say that they had someone that died in the emergency room, and if they had the ability to put them on ECMO, they might have been able to save their life.
It’s possible that there could be a time when smaller hospitals could do the initial work to attach a patient to ECMO. The medical community is already working on something he calls “ECMO in a Box.”
“It’s very streamlined from a medical supply standpoint and very easy to use,” Teman said. “I don’t ever see this as something anyone could do at home, but I do see it as an opportunity.”
The hard part, however, isn’t connecting someone to ECMO, Teman said. The challenge is managing the patient once they are connected to the machine.
“They can transfer them over here, and we can start evaluating them for other therapies to see if they are able to recover their heart and lung function and come off ECMO,” Teman said. “But if they’re not, then we have the opportunity to get them a heart transplant or a lung transplant or a heart pump, or all these other things, so it’s all part of the continuum.”
With recognition during COVID and through news articles, ECMO centers are starting to get more inquiries from the public about treatment for their loved ones.
“I think most ECMO centers are certainly willing to have those conversations,” he said. “There’s going to be many times where the answer is, unfortunately, going to be no. Not everybody can be saved with this therapy, but I do think there’s a lot of opportunities to save lives.”
ECMO works best in cases where an extra hour or day or week or month could help a person survive.
“Every single year, there are patients that come in on death’s door, whether it’s from a heart attack or bad pneumonia, COVID or trauma. We’ve got young patients that have traumatic injuries and develop lung or heart failure. We’ve had college students who develop an acute infection of their hearts, and we’re able to put them on ECMO. That’s why we do this. Those are survivable things that all they need is time.”