LECTURE: Legend Bob Bartlett talks about ‘ECMO: Past, Present and Future’

This is a great lecture from one of the legends of ECMO, Dr. Bob Bartlett from the University of Michigan.  Dr. Bartlett is a pioneer of ECMO/ECLS and established the ELSO (Extroacorporeal Life Support Organization) registry. This lecture was recorded at the the Karolinska Institute in Stockholm Sweden in 2012.

I highly recommend you carve out 60 minutes of your time and enjoy this great lecture:

NEW ARTICLE: Emergency department initiation of percutaneous cardiopulmonary support for traumatic cardiac tamponade with coagulated pericardial effusion

2014 case report just published out of Japan. Interesting. Our 2012 ECPR study was cited here.

Why not simultaneously try the pericardiocentesis during the cannulation procedure?

 

But this is good proof of concept for another rare application of ECLS in a trauma scenario.

This article is open access, thanks to Elsevier, so here it is:

2014 coagulated cardiac tamponade with ECPR

WHERE in the World is Zack Shinar??!!

Cameroon, Africa

Cameroon, Africa

Zack is in Cameroon, Africa for 3 weeks visiting his amazing brother, who is a missionary over there.  He has very little access to the outside World and is overwhelmed with the dichotomy of our “world” of medicine and what he is experiencing over there.  Here is yesterday's email:

“Seriously rough day today.  I helped take a post-op c-section with sepsis back to or.  She died later today.  Under resuscitated.  I think I could have done better.  Open skull fx mca is looking awful.  I can see about 30 percent of his r brain missing from plain exam.  We washed him out today.  Plan to use Dr. xxxxx's fat transplant idea when cleaner.  Still not sure exactly best plan for him.  I put a pin in a kid with a mangled foot.  Tendon repair is not really an option.  Infant died of pneumonia.  Malaria everywhere.  Coartem for all!  Certainly humbles me to pray, makes me question the massive discrepancies in the world, and yet makes me value their simplicity of life so lacking from my current state.” ~Zack

 

 

 

 

Today, Zack sent a photo of their “Difficult Airway Cart”. This stuff really makes you appreciate what we have!

Airway

The “Airway Cart”

 

 

 

 

 

Here are some more shots Shinar just sent:

Cameroon OR

Cameroon OR

Shinar on Cameroon Radio Show

Shinar on Cameroon Radio Show

Cameroon EMS!

Cameroon EMS!

 

Resuscitation table

Resuscitation table

photo 3

Patients

Patients

photo 2

 

 

 

 

 

 

 

EDECMO Episode 8 – “Prime Time!” – prepping the ECMO circuit for action!

Dr. Jim Manning

Dr. Jim Manning

The ED ECMO crew left the www.edecmo.org World Headquarters in May 2014 to meet with Dr. Jim Manning at the University of North Carolina Chapel Hill to do some animal experiments incorporating ECMO.  Dr. Manning is an Emergency Department attending physician at UNC-Chapel Hill and has a distinct interest in endovascular resusscitation. Specifically, Jim is working with a new catheter called the “Selective Aortic Arch Perfusion” (or SAAP) catheter in non-compressible abdominal and pelvic trauma. The SAAP catheter functions much like REBOA (resuscitative endovascular balloon occlusion of the Aorta) and we will compare and contrast those two technologies in the near future.

Dr. Manning's expertise in animal models of resuscitation drew us to North Carolina. The experience was far beyond anything we could have expected and much much more will be posted over the coming months!

The Manning Lab

Dr. Manning, Zack Shinar, Shane McCurdy, and Joe Bellezzo

The Experiments

The Experiments

Manning in prep

Joe Bellezzo MD

Joe Bellezzo MD

 

“PRIME TIME!” ~Nuances of priming the ECMO circuit with Greg Griffin, the Chief Perfusionist at UNC-Chapel Hill

Greg Griffin, Chief Perfusionist - UNC Chapel Hill

Greg Griffin, Chief Perfusionist – UNC Chapel Hill

The folks at UNC-Chapel Hill have a very active inpatient ECMO program. While they aren't yet doing ECPR in the ED (and we hope to help change that!), they do a lot of ECMO.  Greg Griffin has been the Chief Perfusionist at UNC-Chapel Hill for the past 3 years and has been a perfusionist at their facility for over 20 years. While in Dr. Manning's lab, Zack had the opportunity to sit down with Greg and talk in depth about ECMO, the Maquet Cardiohelp ECMO machine, and some pearls and pitfalls of “priming the pump!”

Introduction

  • The ECMO circuit consists of:
      1. The machine: which is basically a centrifugal pump (a machine that generates forward blood flow via centrifugal force), an oxygen supply, and a water bath to control the temperature. Simple.
      2. The circuit: the circuit is a.) the tubing that the blood flows through, b.) a membrane oxygenator (a small plastic box that contains a membrane…blood flows across that membrane while oxygen is added to the blood and CO2 is removed), and c.) the pump head (a plastic chamber that transfers the centrifugal forces from the pump to generate forward blood flow).
        • The combination of the tubing, oxygenator and pump head are also referred to as the “disposables,” because they come into contact with the patient's blood, and are later disposed of.
      3. The cart: which is the support structure that holds all the equipment.
  • Definitions:
    1. Priming the circuit = filling the entire circuit with fluid. Priming is done by hanging the fluid higher than the circuit and letting gravity fill the entire circuit.  At the present time, we prime with a crystalloid solution.
    2. De-Airing: removing all air bubbles from the circuit. The nuances of this are discussed in this episode.

The Formula One Racetrack Analogy

  • When the circuit is set up and the pump is flowing, a maze of tubes seems to spread haphazardly about the machine.   What appears complicated and confusing is really quite simple:  The circuit is nothing more than a big oval tube with blood flowing around the oval, not unlike an oval auto racetrack. When priming the pump you run the “cars” through the oval until you are ready to initiate bypass and add your patient to the circuit. Priming involves filling the circuit with fluid and de-airing the entire system.
  • When it comes time to put your patient on bypass, you divert the “cars” from the “racetrack” and have them take a detour into the “pit,” which is your patient. Oxygenated blood that has just left the oxygenator exits the oval “racetrack” via detour-tubing, enters the arterial cannula, and enters the patient's arterial system.  Deoxygenated venous blood that is returning to the heart is captured by the venous cannula (who's tip is at the right atrial inlet) and directed back onto the “racetrack”.  The circuit once again passes the blood through the centrifugal pump (generating forward blood flow) and then, again, through the oxygenator.
  • At any time you can elect to run your “race cars” through the circuit only (staying on the track), or through your patient. One or the other…but not both at the same time.

 

In keeping with the “North Carolina” theme, here is the Charlotte Motor Speedway in Charlotte, North Carolina:

Charlotte Motor Speedway

Racetrack mockup 2.001

Racetrack mockup 3.001

 

Now, lets take another look at a diagram of the whole circuit:

 

Maquet Circuit mockup.001

Enjoy the Interview:

Zack Shinar Teaches Basic Resuscitation in Cameroon, Africa!

For the next three weeks Zack is in Camaroon, Africa!  Obviously reviewing just the basics of resuscitation and triage, hopefully Zack will return (at all!) with some insightful thoughts on how far we've come in First World medicine.  When he gets back, I'll have Zack post a note on his experiences and what WE can learn from their World.

Here are some initial pics of Zack teaching the locals:

 

 

Meducation in Africa

Meducation in Africa

Meducation in Africa!

Meducation in Africa!

And of course they need a “Crash/Resuscitation Cart” at the Medical Clinic!!:

photo

 

Google Glass during ECPR!?!?

I just received Google Glass as part of their “Explorer program.”  Initial impression is that this may be a very interesting way to dip my toes in the idea of a “heads up display” during resuscitations.  Going forward I will be video-recording ECPR cases using both Glass and my Go-Pro…for educational purposes.  As many of you know I've recorded several ECPR cases and some of those videos are already on the website.Glass doctor

In addition I've loaded several resources into the device for instant access: weight-based range of cannula sizes, ideal flow rates, etc. All can be pulled up hands free.

Ideally I'll be able to get Point-of-view video for upload.

…more to come.

~Joe

The ED ECMO boys are speaking at Essentials of Emergency Medicine in San Francisco!

Zack, Joe and Scott will be doing a whole morning this year at the 2014 Essentials of Emergency Medicine in San Francisco November 7-10 at the Marriott Marquis. And Weingart is mediating!  We are doing some really cool stuff on “EXTREME RESUSCITATION!”  Take a look at the itinerary below:

 

Screen Shot 2014-04-19 at 12.05.01 PM

 

This is THE premier conference for Emergency Medicine and Critical Care specialists.  We have no disclosures regarding this conference except to say that it TOTALLY ROCKS!

Register for this conference now!

See you there!

NEW! Mobile-optimized version of www.edecmo.org

Weingart designed the NEW mobile version of our site!  Navigate to the site via any mobile device (iPhone, Android, etc) and check it out! There's even an audio player embedded so podcast episodes can be streamed directly to your device.

 

Better yet, use any scanning app and scan the www.edecmo.org custom barcode, using your mobile device, and you'll be taken right to the mobile-optimized site: QR

 

 

Don't have a scanner app on your device?  I recommend the following FREE scanning apps:

iphone/iPad: QR reader, QR Code Scanner and Reader, or Quick Scan

Android: QR Reader or QR Code Reader

The Resuscitation Cart

Zack and I have talked a lot about the “Resuscitation Cart”.  Here is our Resuscitation Cart 2.0 which was just overhauled.  This cart has almost everything we use during resuscitations in our ED and gets brought to the bedside for every code or crashing patient.

For non-ECPR cases, the only additional equipment needed are your crash cart, ultrasound machine, RSI equipment, and (optional) your mechanical chest compression device.  EVERYTHING else is on this cart including IV ACCESS, IO, Rescue Airway supplies, etc.

For ECPR cases we use the above items in addition to the ECMO cart (contents checklist previously posted) and the ECMO machine.

Resuscitation Cart

Resuscitation Cart

Drawer 1

Drawer 2

Drawer 3

Drawer 4

Drawer 5

Side Bins

 

 

 

 

The Resuscitation Cart

The Resuscitation CartResuscitation Cart Inventory April 2014

 

***special thanks to Melody Shedlosky RN for assistance with establishing the SMH resuscitation cart.

 

EDECMO Episode 6 – On Life & Death with Peter Rosen

Today I sat down with Dr. Peter Rosen to talk about the topic of life and death.

Peter is a close friend and one my mentors throughout my training and career. I trained under Peter as a resident at UCSD and I whenever Peter is in town I try to meet up with him to talk about anything BUT emergency medicine!  He usually tries to goat me into a tennis match but I've been beat up too many times to take the thrashing anymore!

Today I convinced Peter to go on-the-record with me and talk a little bit on the topic of life and death, since the topic is so important to what we are doing with ECPR.  Peter has spent decades watching gadgets, toys, and technology come and go – and carries a very understandable skepticism toward any process that artificially prolongs life.  I'm not sure I convinced him during this session but my career goal will be to show him that ECPR works in the right patient population.

Hearing Peter talk is always fascinating and I hope to have him on regularly on the podcast.

Enjoy the Episode: