EDECMO 17 – The Reanimateur: Lionel Lamhaut on Pre-Hospital ECPR

In this episode Zack talks with Lionel Lamhaut, a physician who is heading up their pre-hospital ECMO program. Yes, they are really doing ECMO in the field.

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In this episode Zack sits down with Dr. Lionel Lamhaut, an anesthesiologist and “reanimateur” from Paris, France, about their pre-hospital ECMO program. Yes. You read that right. This group from France is sending an ECMO team to the scene of the cardiac arrest and, in appropriate cases, initiating ECMO in the field. Does this really work? What are the logistics of making this happen? Is this the future of pre-hospital resuscitation? Does this model translate to EMS models in other countries? And most importantly, does this finally challenge the despicable “Termination of Resuscitation” (TOR) policies that have been metastasizing throughout our EMS communities?

The Plague of the TOR:

In the U.S. the “Termination of Resuscitation” (TOR) policies are plaguing our pre-hospital colleagues. By TOR ideology, paramedics arrive to the scene of an arrested patient and work the patient until either ROSC or death. This is the “stay and play” model at its extreme. They simply don’t transport patients to the hospital unless they achieve ROSC in the field. No ROSC = No transport. Dead. We have become victims of our own success; Paramedics are now so good that they can do (almost) everything in the field that could be done at the hospital. And, as the argument goes, transporting patients only results in: 1.) lesser-quality chest compressions, 2.) potential EMS/rescuer injury (by not being strapped into their safety harnesses during transport), 3.) inherent public dangers in transporting patients “Code 3” (lights and sirens), etc. In other words, Emergency Departments traditionally couldn’t offer anything that medics could not offer in the field and the quality and safety of the patient and the rescuers was worse because of the transport.

Well…that all changes with ECMO. Here are the three current options:

San Diego: In our Emergency Department Emergency Physicians initiate ECMO. We still suffer from the policies of TOR but try to encourage our EMS team to consider transport of certain patients.
Australia (CHEER), rescuers initiate CPR with a mechanical chest compression device, begin intra-arrest cooling, and transport immediately to their ECMO/CPB center (The Alfred Hospital in Melbourne). For more on CHEER and the Alfred Hospital in Melbourne, Australia, check out Part 1 of our interview with Dr. Stephen Bernard on EDECMO Episode 14. And Part 2 of our interview with Dr. Bernard was EDECMO Episode 15.
France: Pre-Hospital ECMO. Hell, the word “Reanimation” is painted right on the front of the ambulances in Paris! This is what this episode of the EDECMO podcast is all about.

Mobile ICU = First responders

-physician on ambulance

-“Exactly like trauma room”

Prehospital ECMO Team

– 2 senior non-surgeon physicians with expertise in ECMO, 1 nurse, 1 paramedic

– Maquet™ Cardiohelp

– 2 units of packed RBCs and 2 units of FFP

– Sedation

– Therapeutic Hypothermia

Approach

– Seldinger technique with modified cutdown of proximal vessels. They FIRST do a cutdown to expose the femoral vessels. They then insert the needle DISTAL to the femoral cutdown and visualize direct vessel access within the open surgical field. That way, the cannulas are actually placed percutaneous while vessel access can be directly visualized. Lionel says that this approach is actually faster and safer than just blindly stabbing around with the needle as is done with a blind percutaneous method.