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In this episode we talk about how we prepare for, and run, our codes. When we began incorporating ECPR into our resuscitation strategy we found ourselves saving patients who would have otherwise died. The traditional nihilistic approach to the arresting patient was overturned with ECPR by providing hope that wasn’t previously there. Naturally, we took a closer look at each element of the code, from the time the patient hit the door to the time we started the pump. And we realized we were doing a lot of stuff wrong. Here is how I do it:
1. Medic gurney entry: If you’re doing ECPR, then vascular access of the femoral vessels is a top priority. Most of us are right handed and prefer to access the femoral vasculature on the patient’s right. But that’s EXACTLY where the medic gurney offloads the patient- big mistake. Time is wasted waiting for the medics to move the patient to your hospital gurney, remove monitor leads, pack up the monitor, avoid pulling out IV’s and then leave the room. Only then could the “line doctor” push the ultrasound machine into the room, disrobe the patient, gown up, place a sterile US probe cover, prep the field and get to work. That’s precious minutes wasted. Stop doing that! Bring the medic gurney in on the other side! Your “line doctor” is already completely ready to go.
2. Protocolize EVERYTHING: ACLS provides a protocolized framework for running a code. But what about all that stuff that happens from the ambulance bay until care is transferred to you? And can we improve on the current ACLS algorithm? Most of us appreciate that protocoling doesn’t restrict us; in fact, quite the opposite. A protocol allows cognitive offloading of important, yet routine, steps in a process which frees us to focus on tasks specific to that patient.
If you are considering establishing an ED ECMO or ECPR program at your facility, I highly recommend that you take a close look at everything that is done from the time the patient hits your door to the time the ECLS pump is started. We aren’t saying this is the only way to do it, but this is how we do it:
Anticipating the Arrival of an Arresting Patient:
- Staging the room: not unlike a theatrical play, each person and each piece of equipment has a specific role and a specific position in resuscitation suite. Do it the same way every single time.
Some roles that are unique to our resuscitation team:
- “Line Doctor”: MD responsible for femoral vascular access
- “Code Doctor”: MD responsible for running the code and decision-making
- “Code Team Leader”: RN responsible for timing of important events (ie drug delivery, shocking, pulse checks, etc). This RN also does computer-based charting.
- “Med/Electric Nurse”: RN responsible for pushing drugs and delivering shocks
- “Resuscitation Cart”: lives just outside the room and has two shelves and house the following:
- Quiet the room: as the medics enter the room, quickly remind everyone to limit unnecessary noise.
Patient Arrival:
- The paramedic gurney (with ongoing CPR) enters the room on the right side of the room (if you are looking from outside to inside the room), not the left (which is how you are likely accepting your patients now.)
- After transfer of the patient from the medic gurney to the ED bed, chest compressions are immediately assumed by “Chest compressor #1”. compressions then move back and forth between the two “Chest compressors” at pulse checks.
- Since femoral vascular access is a huge focus, I would also recommend that you assign a free hand (RN or tech) to “groin access,” who is standing outside the room with trauma shears in one hand a bottle of betadine in the other. Once the patient is moved from the medic gurney to the ED Bed, that individual is tasked with stripping the pants off (by cutting or pulling) and drenching the groins in betadine. It becomes an efficient task for the “line doc” to drop a drape, place the US probe, and gain femoral vascular access.
- Of course, the need for both of these human chest compressors (and valuable real estate in the resuscitation room) is eliminated if you have a mechanical chest compression device such as the LUCAS2:
Great episode! These logistics and small tips are so important, and when I think of it, this tactical stuff is important for all/any medical interventions. And you never learn or read them anywhere, but you experience them after starting to work as a doc. Learning the tactics of doctoring early on might make for better junior docs. Or, like here, helping already experienced docs doing new things like ECPR better from the get go, instead of repeating all the challenges you probably faced when starting your ECPR program. Anyway, this episode made me think, and become much more aware of how we’re running codes as well as trauma. Even without ECMO.
A few comments:
1) On CPR, have you considered cutting out the pulse check, or at least making them less frequent and instead relying on EtCO2? Would love to hear your thoughts on that.
2) Great point on code team leader. I love how you’ve handled that and focused on team instead of work titles. We’ve structured it slightly differently, but in effect it is the same. A doc is still the code team leader, but we do have a nurse that keeps track of all the timings and calls out time to next pulse check/med etc and keeps track of total time, number of loops and so on. So in reality, that nurse runs the code, but the doc is still team leader and can intervene/override that nurse if appropriate.
3) I love how you acknowledge that arrests are infrequent events, and even in the biggest hospitals, the number of codes is divided between the number of docs. Important point!
4) We already take the ambulance gurney in on the left side of the patient bed, so we’re one step closer to an ECPR program 😉
Thanks again for an inspiring episode!
Thomas, thanks again for the comments and thoughts. To answer your questions: 1. Pulse checks: I still do them but also use ETCO2: a jump in ETCO2 (usually by 10 points or more) will prompt a sooner pulse check. For us, we want to know asap when a pulse is obtained because placing that art line during CPR is infinitely easier with a pulse. 2. Code team leader: Its driving with airbags and antilock breaks, man!!! I can now take a corner at high speed and know I’m encased in a cocoon of safety! …or something like that. I don’t have to worry about the rote stuff now!
Hi ED-ECMO, love your show. very importent stuff.
In our shop we have just started a ECPR program and have to date put 5 patients on the pump. Our setup is a little bit different: we accept our patients (on LUCAS2) in the cathlab with a interventional cardiologist as teamleader. We do the usual cannulation as for PCI and do a “quick and dirty” coronary angiography to deal with an obvious occlution. If the patient doesnot regain ROSC we (the cardiologist with a thorasic surgeon) continue the cannulation and procede to VA ECMO.
If the PCI takes to long time or is inconclusive, ECMO or Impella(rotapump) is initiated. and this gives us time for a proper PCI.
Hi Joe. Love the set up and approach with only one slight difference. I am in EMS and use the Stryker Power Pro stretcher. It is equipped with a rack to support our LP15. It is attached just below the patients right knee. Attempting to transfer from the right as you suggest is problematic. I have been delivering more patients to the ED in a ROSC state and am using the post arrest hypothermia guidelines set forth by Sunnybrook Base Hospital in Toronto, Ontario. Having IV’s established and the other monitoring devices including 12 lead, I find the transition in the ED easier from the left to disconnect and draw the patient over. Thank you so much for all that you do.
Rob,
Great comments and thoughts. I would make the following arguments:
1. If the patient has achieved ROSC, then you can bring the patient into the room on either side – and in your case the left is just fine. However with CPR ongoing I would bring them in on the right and just completely disconnect your monitor from the patient, continue compressions, and transition the patient to the hospital gurney. In the ER we are going to put the pt on our own monitors and continue compressions for another two min anyway…so disconnecting your monitors is just fine.
2. The only real reason to do the transfer the way we do it is to expedite right groin vascular access…because we believe in hemodynamic-guided resuscitation/CPR using a transduced art line and can then transition to ECMO for failed ACLS. IF your hospital does neither of these, then moving the patient into the room on the left (the traditional side) is just fine.
3. Now, what about doing the transition in the ambulance bay instead? There is much more space out there and (since I’m a huge fan of mechanical chest compression devices) we transition to LUCAS2 in the ambulance bay.
Thanks Joe. All valid points. I will discuss your suggestions with our Emerg team lead coordinator and see if we can implement better transition strategies.
I am trying to find research done on this novel topic for one of my classes, however, I am struggling. Can you point me in the right direction?