“The Story of Ralph”

Our First ECPR Case:

It was July 28, 2010. That morning Zack had just given our ER group a presentation on a “new” intervention: ECMO.

Zack and Joe were on shift that same night.  The radio call came in: 59 yr old male with chest pain, EKG shows ***Acute MI***.  Minutes later the medics came back on the radio with this message: “Sharp, be aware your patient just coded.” Here is the actual radio call (with subtitles):

Ralph radio call – “your patient just coded!” from Joe Bellezzo on Vimeo.

Ralph was in refractory VFIB. Zack threw everything at him: every drug in the code box and an uncountable number of shocks – all unsuccessful. Joe and Zack put Ralph on ECMO. His case was initially thought to be unsurvivable and he was taken to the ICU, where he began moving and checking his watch! So he was taken to the cath lab and his 100% LAD lesion was stented.  9 days later Ralph walked out of the hospital (refusing to take a wheelchair).  Ralph is alive and well.  We do a yearly 5k event at Thanksgiving every year. In return, we've forced Ralph into a state of persistent guilt and retribution…and make him to come with us to various speaking events!!!!

In late 2010, we presented Ralph's case at Grand Rounds at USC…and as always we guilted Ralph into coming along.  Mel Herbert recorded that event and put together a little video about his story.  Here is Mel's video (note that the credits at the end should say “Sharp” hospital, not “Scripps”):

“The Story of Ralph” – 2010 – By Mel Herbert MD from Joe Bellezzo on Vimeo.

***Many thanks to Mel Herbert and EM:RAP for allowing us to share his video on our site!

 

Around the same time our hospital produced a video on Ralph's story as well. Here is that video:

July 2010: ECPR saves a patient in refractory V-Fib from Joe Bellezzo on Vimeo.

 

July 28. 2014:

…and today, July 28, 2014, Ralph and his wife Suzette stopped by our ED to say thanks. Today is the four-year anniversary of Ralph's remarkable resuscitation after VF arrest.

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Why You Should Subscribe to Podcasts:

From Wikipedia:

 podcast (or netcast) is a digital medium consisting of an episodic series of audiovideoPDF, or ePub files subscribed to and downloaded through web syndication or streamed online to a computer or mobile device. The word is a neologism and portmanteau derived from “broadcast” and “pod” from the success of the iPod, as audio podcasts are often listened to on portable media players.

Podcast producers create content that can be downloaded, usually for free, and enjoyed at your leisure.  Because the podcast episodes are downloaded to your computer and/or smart device, the content can be consumed at any time (ie in your car, while exercising, while walking the dog, etc) – a concept called time-shifting.  You don't have to “tune in” when the show is on the air – you can listen whenever you like.

The true magic of the podcast is that you can “subscribe” to them.  Episodes, or “shows”, will be pushed to your computer/smart device  whenever new content is published.  So you don't have to  constantly check in to see if new content is available – Its like magic – it just shows up in your podcast queue.  You can subscribe to as many, or as few, podcasts as you prefer.

How do you get access to all this free goodness?  The most common method is to subscribe to podcasts via iTunes.  Simply go to the iTunes application on your computer, open the iTunes Store (on the left panel) and click on the “podcasts” tab on the top right.  Then just browse away.

Me? I subscribe to several different podcasts. The ED-based medical podcasts I recommend include Scott's amazing Emcrit podcast, Cliff Reid's Resus.ME, Rob Orman's popular ER Cast, Matt & Mike's Ultrasound Podcast, and David Newman's Smart EM, just to name a few.  I'd also recommend Minh Le Cong's PHARM (pre-hospital and retrieval medicine) podcast – which has a nice pre-hospital take on things.

But it isn't all M'Education!  There is a TON of high quality content out there: entertainment, motivational stuff, inspiration, sports,  “ebooks,” productivity, and all kinds of other stuff.  Browse away. Hell, its all free!

How do they all do it? Well, the big names in podcasting are able to advertise and work with sponsors, but much of the content is produced purely out of passion for the subject matter.  Since you can “consume” the content of podcasts when you want, how you want…and where you want, podcasts are bypassing terrestrial radio, internet radio, and audio recordings insofar as how media is being appreciated nowadays.

To better explain how this process works I put together a short video on navigating iTunes and subscribing to podcasts:

 

 

iTunes Review instructions – edecmo podcast from Joe Bellezzo on Vimeo.

Chatter causes IVC Trauma!

As we mentioned in our recent podcast Episode 8: “Prime Time!”, and as Weingart mentioned in his recent episode of the EMCRIT podcast:  Podcast 123 – Selective Aortic Arch Perfusion (SAAP) with Jim Manning, Zack and I were at UNC Chapel Hill in Jim Manning's lab doing several experiments in a pig animal model.

During one of the experiments we did a thoracotomy and what we saw was really impressive.  We all know that the ECMO lines will “chatter” when the RPM's were cranked up too high…caused by turbulence in the venous intake line when the negative pressure of the pump requests more volume than the IVC can deliver.  But I don't think any of us appreciated exactly what was happening at the IVC.

Bottom line: Chatter beats up the IVC and should really be avoided!  This video will raise your eyebrows!:

 

 

Chatter IVC from Joe Bellezzo on Vimeo.

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

 

 

 

 

 

 

 

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:

 

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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