In this video, anesthesiologist Dr. William Vernick describes how his system prepared themselves for patient transportation, specifically in regard to ECMO. He explains how using specific tools (CESAR trials) and thought processes helped the team understand what abilities they had. By reviewing the known limitations and mapping out an effective communication tree, they were able to put together a plan.
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So um lessons learned from building a long rescue program. So when we first started thinking about this, back in 2013, there was no courses to go to no books to read. Um The idea really came from uh stories of successful programs in Europe during the H O N H one N one epidemic and discussions with some of our colleagues in Colombia like Dan brody, which is one of the few programs ahead of mobile mobile teams uh particularly back then, I have no disclosures. So uh the seizure trial was one of the landmark papers. Hard to believe it's over almost 15 years old that really helped the with the rebirth of uh the use of VVE mo and air. Yes. Um uh at, at the time, we, you know, we, we knew we knew there was a need and we also knew there was some evidence to support it. One of the things the Caesar trial helped uh show was something that we already knew that uh that, that patients uh with A R DS. Um Well, it was great. They could, they could uh receive ECMO at tertiary centers. There was a whole world of, of patients who just happened to go to a different hospital and really didn't have access to this lifesaving technology. Um You know, these are definitely the sickest patients in the hospital, um almost at any hospital. So getting them to a tertiary center can be extremely challenging. And we certainly saw some of the morbidity and even mortality associated with trying to transport these patients. Uh without acma. We also knew there was a need for regional centers of excellence um in, in this field. And we also knew That this, this uh excellence couldn't be available just when it was convenient, it had to be available 24/7. So we had to look at ourselves and say, was this something we could do and and if we, and what did we have to do, what do we need to be able to do it? So we needed transport capabilities. Fortunately, at Penn, we already had the, the great team of Pennst star um who are always willing to give us a ride. Um They uh were already highly expert uh expertise at transferring sick patients. Um But you know, they, they were more than willing to be able to increase their workload and, and help us with mobile ECMO cannulation. You had to have a call center. So when someone called, they, you know, when referring is calling and they, and they're desperate, they don't want to make 27 phone calls. They want to get to the right people. Um we also were fortunate to have that already in place. We'd have the equipment available and for the, the administration was willing to take a chance and, and buy us the mobile equipment that we needed. Uh we believe that we, we had the know how as staff, but we, we had to be able to create the availability to have that 24/7 availability, which certainly wasn't easy. And one thing, we didn't quite appreciate that when we were first developing, all the other aspects was was marketing. And I don't mean, uh you know, TV, commercials or brochures. Uh We really had to hit the pavement and go out and, and market ourselves to com community hospitals and critical care physicians, uh particularly back then when, you know, the, this wasn't quite as, as accepted as it is now that, that E O is a, an appropriate therapy for A R DS. Uh One of the things that we always found, you know, somewhat a amazing was that after you, we went out and visited up AAA critical care team that we've never been to a hospital hospital, we'd never been to or we never heard from and often never even heard of prior. Within a 11 to 2 weeks, you'd magically get a phone call from these people saying, hey, I have this person, I they might be a candidate. What do you think? So, you know, this was a one of the most important things we, we, we did and again, one that we didn't really think about when we went through all the things that we had to set up. Um, so again, we did a lot of ground work before we got started. You know, these are just some of the, some of the things they had to think about, um, get licensing in multiple states being in the, in the middle of a uh tri-state area. Um, you know, Jersey licenses Delaware licenses on top of our Pennsylvania license. We never bit the bullet and went down as far as Maryland or New York. But, you know, we thought about it. Ok. Uh we definitely had to establish an effective communication tree. So not only do we need our transfer center to be able to get, get the right triage these calls uh to the right people, but we also, you know, couldn't spend 40 minutes, you know, calling different people. Are you available or not? Um so we had to really uh focused on, on, on streamlining our communication process. Um So the mobile team consisted of our, our, again, our pensar crew, our critical transport nurse as part of that Pennst star crew, um, as well as a perfusionist that again had to be available 24 7 to be able to go out and being pulled away from the other responsibilities in the in the uh in supporting cardiac surgical cases. Uh and we have, we had 1 to 2 positions, whether it be cardiac anesthesiologist or a cardiac surgeon or a combination of the two uh showing off of some of our toys, our uh transport ambulance as well as our helicopter. Um and you know, just showing some of the, you had to be, uh we had to be a little creative to fit in on these helicopters sometimes. So when you, when you go out and, and do a mobile uh mobile uh case, I kind of sometimes it's akin and, and you, we've gone to all different types of hospitals, you know, some, you know, from other other academic centers to um almost a um a former hospital that became a minute clinic. Um It's, you were I i it's sort of akin to, you know, uh being a navy seal, being dropped behind enemy lines. Um You have to, you have to get in quick, you have to be precise and there's really no, no room for any complications, particularly at some of these smaller hospitals. So image guiding uh guidance is, is absolutely critical. Um When we first started, you know, we, we insisted on, on using floral and on top of uh echo that we would bring, uh we kind of quickly learned that, you know, the, the logistical barriers associated with going to so many places and asking them for flora was just kind of a nonstarter. Um But T E really is absolutely critical. Uh, we've, some of the things that we've gone in and, you know, the stories can be quite different. You know, we've found flail, mit leaflets, we've found, you know, massive a sds, uh, right and left heart, uh, you know, that were failing that, you know, again, not really part of the story. So against, uh, some of the equipment we put together and, you know, what we also learned is you gotta bring the whole team together. Um You know, when you first you, you start up, you know, these are all the, all the services that are gonna be affected by what you're doing. And when, you know, for example, the ID physicians, all of a sudden were faced with, you know, a doubling of their critical care consults. Um you know, they, they had to be brought in as, you know, again, as, as really part of the team that, that you need to manage these patients. So when we first turned on, turned the phones on, we weren't quite sure if anyone was gonna call. Um But, you know, in, in the first year we had 100 and six calls, year two, we had 100 and 40 calls. So they definitely proved that there was a need, this is our initial in inclusion exclusion criteria. And in that first year, we, we definitely uh had some successes. We also had some challenges. Um So what we learned very a couple of things we learned very quickly that were absolutely critical. One is you had to go back out and reach to your referring physicians and do some education on, on when to call on who to call on and when to call. Um, you know, kind of bring up the idea that don't wait till the last second, we'd rather hear from you earlier than later. And that it doesn't have to be a binary decision that night. It doesn't have to be a yes or no. It can be, hey, this can be a couple day process, you know, let, let's see how they're doing. Uh maybe a day from now, two days from now, but definitely waiting too late is the last thing we want. Uh The other thing that we, that we learned quickly is that you can't just take a phone call and, and just expect that you're gonna get all the information you need. Um We, there's a lot of work that goes into it, you know, discussing with the person that's on the other end of the phone. Oftentimes the phone calls are coming. Um, again, off hours. Uh It may be a hospitalist. It may be a, you know, a person that's never seen that patient until they picked up their shift an hour ago. Uh They're just not going to know some of the details that um about the patient that you need to know. Uh We almost never take a patient without, again, doing more detailed work on the, on from the person that's calling as well as talking to the family members. You know, what, what you get sometimes is, uh, from the, well, I think they're a walkie talkie and again, which is one of my least favorite terms. Uh, but when you go back and, and you really speak to the family, um, and they might what you get what that was a walkie talkie turns out has been, you know, bedridden for a year. Um It hasn't walked, you know, that's not the type of patients you want to bring in. They're just not gonna do well. So, you know, those were some of the, some of the big learning things that, that we had to get to. And So year two with 140 calls, we were pretty proud of this. Uh we got uh survival went up to 84%. So showing that, you know, when you put these things in the right place, it does make a difference. So everything was going great and, and then COVID hit. So COVID COVID, ECMO was a totally different animal. Um What when you went from, you know, an average ECMO run of 78 days. Um, you know, a long one might be a couple of weeks to, you know, we're getting up to, you know, you know, over 50 days and survivors and then a cruel twist of fate, you know, my patients who died. OK, I Gotta go fast, uh, up to 60 days. So we thought, you know, going into COVID, we thought we were pretty good and then comes a, a 30 year old with two kids, um who, who needs to get home and has lungs that look like this. So it was just again, like a totally different animal. The lungs were just incredibly fragile. Uh pneumo authorities, they were at risk for bleeding, uh you know, tricks chest tubes are all, you know, just life and death procedures when they weren't. So, you know, when they, we didn't have to think about it quite that hard prior uh resource management. Um You know, you're getting, you just don't have room for all the people that are coming in and goal cares. I know we, people uh discussions in advance, people talked about it. You know, when you can keep a healthy person alive almost indefinitely on ECMO, whatever goal carry discussion you have before they arrive. It, it's, it's, it often doesn't hold the same weight as you know, people will, you know, will tell you whatever they, they think is gonna help keep their, their family member alive when you start things change when you're on day 90. Uh and you, and you still um don't have anywhere to go. So we really had to, you know, adapt and take care of our most challenging patients. We became pruning zealots, you know, 7, 14 day three week pruning trials, late pruning a month out. Um We had to change our antiqua anti coagulation management. We actually were told when we first started that all these patients are, this is all prothrombotic disease. That's what you're seeing. That's why they're so sick. But yet, um our biggest complications were bleeding complications, endocrinal hemorrhages again, chest two bleeds, trick bleeds. Um So we had to get way better at that. We had to get way better at ECMO mobilization. Um rid to transplant paradigms. Uh We learned quickly that, you know, these patients with such lung disease are gonna have right sided overload and certain patients are gonna benefit from right side, heart support from both outcomes, uh renal function, et cetera. Uh there was so much more lung damage in these patients then, you know, once the even when the consolidations were gone, uh there was so much co2 clearance issues, you know, we had to look at things like E core, you know, because as you wake them up and bridge them, uh they may not need anymore, but they're gonna have trouble rehabbing with them with how much CO co2 deficits they have. Um So just a picture of our conversions to Oxy oxy rvad platforms. This is uh E C one of our E core devices. OK. In the last few moments, I'm gonna talk about just some of the, the last lessons though, you know, our, our current lessons to be learned, I think uh right now in, in a post COVID world. But what we're learning is we have to continue to evaluate who we are and what we do. Um uh Even prior to COVID, there was uh programs were, were developing, uh you know, there was more and more ECMO programs, I think CO COVID helped some, maybe hurt some. But regardless, there's more and more people doing E M E C O out out there in our community. Um you know, and a lot of our referring people. So, you know, in the great designation world, I I think a lot of our critical care phys assistants, I would call, I don't, they, they may have been other jobs. Um So, you know, I, you know, in this post COVID world, what we're learning is we have to go back out. Um reme you're referring people, talk, talk to them about all the successes we've had and all the things we can do. And in this world, you know, maybe doing 80 mobile echos isn't realistic. Um Maybe we need to change who, you know what we do. You know, you, you become uh not every, not every ECMO patient needs to come to Penn, but maybe there's, there's probably certain ECMO patients that need to come to a tertiary center that has all these capabilities, uh particularly, you know, and the other thing is, you know, as minimum invasive cardiac surgery helps develop us. Uh and become ECMO physicians, maybe ECMO physicians have helped us uh te will teach us how to make the next steps and platform changes in terms of mechanical support uh for into heart support and other other aspects like right heart support.
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