The Alameda County Emergency Medical Services Agency has led our community’s response to cardiac arrest care over the past two decades. This has included cardiopulmonary resuscitation (CPR) training in schools, software to dispatch citizen CPR volunteers, and dispatch-directed chest compressions.1 We have used the impedance threshold device, pit crew training, and fully deployed mechanical CPR devices on all our engines.2,3 Our agency designated formal STEMI/cardiac arrest centers in 2013 and required all patients with return of spontaneous circulation (ROSC) to be taken to them.4
One goal of these centers is to work toward standardization of therapeutic hypothermia and cardiac catheterization, as well as sharing outcome data and best practices. Our agency also required the purchase of mechanical chest compression devices for their emergency departments and catheterization laboratories. The need for this care in our community hospitals was demonstrated by a recent case of a successful prolonged resuscitation with the use of the mechanical CPR devices for several hours, followed by extracorporeal membrane oxygenation.5
Developed in the 1950s, ECMO was originally targeted for patients with respiratory illness but is now used increasingly to help patients in cardiac arrest. There are two general types, venovenous and venoarterial. The first is used to bypass the lungs in cases of severe pulmonary disease, like acute respiratory distress syndrome or exacerbations of cystic fibrosis. The second is the one used for patients in cardiac arrest. It bypasses both the lungs and heart as it pumps oxygenated blood directly into the arterial system. This takes the patient’s low- or nonfunctioning heart out of the equation while underlying causes are addressed.
Several academic centers and EMS systems have incorporated ECMO either in the field or at tertiary care hospitals with out-of-hospital cardiac arrest patients who have a high probability of cardiac etiologies.6–10 These include patients with persistent ventricular fibrillation or STEMI with witnessed cardiac arrest. All these systems have included the use of mechanical CPR devices to allow for prolonged and consistent CPR during their care and transport. The use of ECMO for these OHCA patients with persistent ventricular fibrillation has yielded survival rates of up to 22%.11
The inclusion and exclusion criteria to select patients for ECMO therapy have been evolving, but most include patients aged 18–75 years with persistent ventricular fibrillation, often with the use of a mechanical CPR device. The American Heart Association has suggested ECMO “may be considered for select patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support.”12
Our community has struggled with the fact that our 12 adult hospitals, seven of which are cardiac arrest centers, are not ECMO-capable. We have academic centers in neighboring counties that perform ECMO and would be willing to accept these patients. There are several hospital-based models that retrieve patients and place them on ECMO, but none are available in the Bay Area. Recently, independent companies like ECMO PRN have been created to fill this critical need. Unlike the hospital-based models, this Bay-area company isn’t meant to just retrieve and transfer patients but rather supplement a hospital’s existing resources to help place a patient on ECMO and assist in their transfer to an appropriate ECMO center.
Providers, Expertise, and Equipment
“We have providers, expertise, and equipment designed to deliver ECMO to the patient at whatever facility they are,” says Jason Chan, the company’s CEO. “Sometimes the hospitals have qualified personnel but no equipment, or perhaps they have no equipment or personnel. Either way, we can bring the people and the equipment to get the patient started on ECMO.
“We have planned with some hospitals to have privileges, in which case we just show up with the equipment, and they do the rest. In other cases we could show up with all our resources and request emergency privileges for the hospital. We require the initial hospital correspond with a receiving ECMO-capable hospital to make sure everyone is on board, and then we can work with them to transport the patient from one hospital to another. We contract with a local ambulance company, which allows us to deploy 24/7 and fit all our staff and equipment.”
Most cardiac arrest centers only have a need for ECMO 8–10 times a year, making a hospital service not cost-effective. With the direction of the Alameda County EMS Agency, we have developed STEMI/cardiac arrest centers, increased the use of mechanical CPR devices that allow new therapies such as angioplasty during cardiac arrest, and now have expanded the use of ECMO in carefully selected patients. Hopefully this will improve neurologically intact survival rates from OHCA by enhancing the final link in the chain of survival.
Advantages of ECMO PRN Model
Prearranged relationship with ECMO receiving facilities, including sharing of reimbursement;
Theoretically any hospital has access to ECMO, if indicated;
Patients too unstable to transfer can be started on ECMO prior to transfer;
Coordinate the availability of open beds;
Education of ECMO centers about the use of ECMO for OHCA patients;
Provision and maintenance of portable ECMO equipment;
Training for cardiologists on placing lines and starting ECMO;
Providing specialized transport and personnel;
Significantly decreased costs for the cardiac arrest center.
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10. Yannopoulos D, Bartos JA, Martin C, et al. Minnesota Resuscitation Consortium’s Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out-of-Hospital Refractory Ventricular Fibrillation. J Am Heart Assoc, 2016 Jun 13; 5(6): e003732.
11. Ortega-Deballon I, Hornby L, Shemie SD, Bhanji F, Guadagno E. Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes. Resuscitation, 2016; 101: 12–20.
12. Brooks SC, Anderson ML, Bruder E, et al. Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2015; 132: S436–43.
Karl A. Sporer, MD, FACEP, FACP, is EMS medical director for Alameda County EMS in California. Reach him at firstname.lastname@example.org.