Life support

ECMO Life Support is a last resort for Covid, and in short supply in the South

The day of discharge from the hospital for Phoua Yang was more like a rally of encouragement.

As she walked out of TriStar Centennial Medical Center in Nashville, Tennessee, she tore herself apart as streamers and confetti rained down on her. Nurses chanted her name as she was released from the hospital for the first time since arriving in February with covid-19, barely able to breathe.

The 38-year-old mother is living proof of the power of ECMO – a method of oxygenating a patient’s blood outside the body and then injecting it back. His story helps explain why a shortage of trained personnel who can operate the machines that perform this extracorporeal membrane oxygenation has become such a pinch point that covid hospitalizations are increasing.

“One hundred and forty-six days is a long time,” Yang said of the time she spent on the ECMO machine. “It was like a trip forever with me.”

For nearly five months, Yang had blood pumping from a hole in her neck and passing through the ECMO cart rolling near her bed.

ECMO is the highest level of life support – beyond a ventilator, which pumps oxygen through a tube through the trachea, to the lungs. The ECMO process, on the other hand, basically works like a heart and lungs outside the body.

The process, more often used before the pandemic for organ transplant candidates, is not a treatment. But it saves the lungs of covid patients time to heal. Often they have been on a ventilator for a while. Even when working well, a ventilator can have its own side effects after prolonged use, including nerve damage or damage to the lung itself from excessive air pressure.

Doctors often describe ECMO as a way to let the lungs “rest” – especially useful when even ventilation does not completely oxygenate a patient’s blood.

Many more people could benefit from ECMO than they are receiving, resulting in a messy triage of treatment that may escalate in the coming weeks as the delta variant spreads to the South and the surrounding areas. rural communities with low vaccination rates.

The stalemate in ECMO stems primarily from the number of people it takes to care for each patient. A personal nurse is required, 24 hours a day. staff shortage that many hospitals in hot areas are facing exacerbate the problem.

Yang said that she sometimes had four or five clinical staff assisting her when she needed to walk the halls of the hospital daily to keep her muscles active. ECMO is unusual as a life support because patients can be conscious and mobile, unlike patients on ventilators who are often sedated. This presents its own challenges, however. For Yang, a person’s job was just to make sure that no pipes bent as they moved, as the machine was literally keeping them alive.

Of all the patients treated in an intensive care unit, those on ECMO require the most attention, said nurse Kristin Nguyen, who works in the ICU at Vanderbilt University Medical Center.

“It’s very laborious,” she said one morning, after a one-on-one shift with an ECMO patient who had already spent three weeks in intensive care.

The Extracorporeal Life Support Organization said that an average ECMO patient with covid spends two weeks on the machine, although many doctors say their patients average a month or more.

“These patients take so long to recover, and they devour our hospital beds because they come in and stay,” Nguyen said. “And this is where we find ourselves in such a stalemate.”

The barriers to using ECMO aren’t just the lack of machines for everyone or the high cost – estimated at $ 5,000 a day or much more, depending on the hospital.

“There are many ECMO machines out there – these are people who know how to operate them,” said Dr. Robert Bartlett, a retired University of Michigan surgeon who helped technology pioneer.

Every children’s hospital has ECMO, where it is regularly used on newborns who have lung problems. But Bartlett said that before the pandemic, there was no point in training teams elsewhere to use ECMO when they could only use the technology a few times a year.

It is a fairly risky intervention with little margin for error. And that requires a 24-hour team.

“We really don’t think it should be that every little hospital has ECMO,” Bartlett said.

Bartlett said his research team is working to make sure ECMO can be offered outside of an intensive care unit – and maybe even send patients home with a portable device. But that’s years away.

Only the largest medical centers currently offer ECMO, which means most hospitals in the South are waiting to transfer patients to a large medical center during the recent wave of the pandemic. But there is no formal way to make these transfers. And larger hospitals have their own ECMO-eligible covid patients who would be willing to try it.

“We have to make some tough choices. This is really what it is: how sick are you and what is the availability? Said Dr Harshit Rao, clinical director overseeing critical care physicians with medical services company Envision. He works with intensive care units in Dallas and Houston.

There is no formal process for prioritizing patients, although a national non-profit organization has started a register. And there is little data on the factors that make some covid patients more likely to benefit from ECMO than others.

ECMO has been used in the United States throughout the pandemic. But there wasn’t as much of a shortage early on when people dying from covid tended to be older. ECMO is rarely used for the elderly or with health issues that would prevent them from seeing much benefit.

Even before the pandemic, there had been intense debate over whether ECMO was just an expensive “bridge to nowhere” for most patients. Currently the survival rate for covid patients on ECMO is around 50% – a figure that has declined as more families of sicker patients lobbied for life support.

But the math is different for the younger ones who make up this summer’s wave of largely unvaccinated covid patients in intensive care units. So there is more demand for ECMO.

“I think it’s 100% that they’re younger patients,” said Dr Mani Daneshmand, who heads the transplant and ECMO programs at Emory University Hospital.

Even as tall as Emory, the Atlanta hospital denies multiple referrals per day from covid patients who need ECMO, Daneshmand said. And calls are coming from all over the Southeast.

“When you have a 30 or 40 year old or someone who has just become a parent, you are going to call. We have received calls for 18-year-olds, ”he said. “There are a lot of people who are very young who need a lot of support, and a lot of them are dying.”

Even for the youngest, who tend to have better odds on ECMO, many are debilitated afterwards.

Laura Lyons was an actress with a day job in New York City before the pandemic. Although she was only 31 when she caught the covid, she almost dead. ECMO, she said, saved her life. But she may never be the same again.

“I was running in New York City a year and a half ago, and now I’m in a wheelchair,” she said. “My doctors have told me that I will be on oxygen forever, and I just choose not to accept it. I just don’t see my life tied to a rope.

Lyons now lives with his parents in central Massachusetts and spends most of his days doing physiotherapy. Her struggle to regain her strength continues, but she is alive.

Since it is a bit like the Wild West to give someone an ECMO bed, some families have made public their despair, while their loved one waits for a ventilator.

As soon as Toby Plumlee’s wife was put on a ventilator in August, he started pressuring his doctors about ECMO. She was in a community hospital in northern Georgia, and the family sought help at larger hospitals, looking 500 miles in all directions.

“But the more you research, the more you read, the more you talk in the hospital, the more you start to see how much of a shortage this really is,” he said. “You get right to the point, the only thing you can do is pray for your loved one – that he will survive.”

Plumlee said his wife placed sixth at a hospital 200 miles away – the TriStar Centennial Medical Center, where Phoua Yang completed his 146-day ECMO marathon.

Yang left with a miracle. Plumlee and their children were left in mourning. His wife died before receiving ECMO – a few days after turning 40.

This story was produced as part of NPR’s partnership with Kaiser Health News and Nashville Public Radio.

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