When I started my nursing career, the concept of extracorporeal membrane oxygenation (ECMO) was terrifying. Knowing a machine was pumping and oxygenating blood outside the body so the heart and lungs could rest was more than my new grad mind could grasp.
In order to care for ECMO patients, my unit required a nurse to have years of experience and be trained on every other device before going to the annual ECMO training. At that time, a single ECMO patient required two bedside nurses and a perfusionist. As a new nurse, when someone told me I wasn’t ready for the class, that it is too complex or not to worry about it, I did not fight them. I was overwhelmed enough and, clearly, if only a handful of people could take ECMO, there was no way I was qualified to take it.
Fast forward two years, and it was finally time for me to take my ECMO class to become trained on this machine. I was terrified. This intense machine draining blood from the body into the oxygenator and back into the body required a certified person to sit and watch it. There was no way I was qualified. However, about one hour into the class, I was hooked. The concept was so simple. Blood was pulled out of the body using negative pressure, through a pump, into an oxygenator where CO2 removal and oxygenation occurred, and then it was returned to the body. That was it. Just some cannulas, a pump, an oxygenator and a blender or an oxygen tank. Compared to the VADs or CRRT, the technology was shockingly simple.
Seeing Is Believing
My first ECMO patient was a young man being listed for a heart transplant. He was starting to decompensate, so the team decided to place him on ECMO before he went into respiratory distress or renal failure. After going to the cath lab for cannulation, he came back to the room in time for dinner. His response was so profound that he never required intubation, his urine output picked up immediately, and he asked for his dinner tray. We propped him up for dinner in reverse Trendelenburg, and I remember the heart failure cardiologist standing next to me, looking over the patient, shocked that he was eating enchiladas hours after we were afraid he wouldn’t make it to transplant. I didn’t realize it was the first time our ECMO program put someone on ECMO before intubation. The physicians’ excitement amplified my own.
A few years later, at our survivors’ celebration, I saw him, now post heart transplant, with his wife and children. I reminded him of the enchiladas, but he had no memory of that day. Up until that day, I had seen ECMO as a last resort. A last-ditch effort before throwing in the towel. Luckily, this paradigm is beginning to shift. Instead, the focus is on mitigating risk of conventional care and intervening before the downward spiral that leads to irreversible damage.
A Nurse’s Role in ECMO
Over the next few years while in NP school, I took care of every ECMO patient I possibly could. I always volunteered to do ECMO transports; we would go to outside hospitals to cannulate for ECMO and bring them back to our unit. We started an ECPR program for out-of-hospital cardiac arrests that were cannulated for ECMO before going to the cath lab. I loved the adrenaline rush and the complexity of these patients. While the shifts were exhausting, I was never bored with an ECMO patient because I was practicing at the top of my skill set. The feeling of tirelessly resuscitating a patient after a cardiac arrest to come back to work a few days later to see them sitting in a chair is unlike any other euphoria.
In 2018, our program started an ECMO specialist program where nurses and respiratory therapists could train on the pumps in order to manage them bedside. In just a few years, I was able to transition from being terrified to even step foot in an ECMO patient’s room to now managing the lines and pump so the patient could walk with physical therapy. As our program grew and the frequency of ECMO patients increased, so did everyone’s comfort level with it. Pretty soon, ECMO was just another device. It no longer required two nurses and a perfusionist and it was not seen as a last resort.
Forging a New Path in ECMO Care
I transitioned to the role of an ECMO nurse practitioner (NP) in fall 2020. Since it was a new role in the hospital due to the rapid growth of our ECMO program, there was little structure about what my role would entail “once COVID was over.” However, my role quickly turned into a supportive position on the unit, given most of the unit wasn’t trained as an ECMO specialist, including a focus on referrals for patients needing ECMO.
Unlike the historical precedent of needing years of experience to take the ECMO course, the pandemic required a change in strategy. With hundreds of consults coming in for ECMO, limited beds and only a select group of nurses trained to take ECMO (the same nurses taking classes on heart transplants, VADs and all other mechanical circulatory support devices), the dated model would no longer work. The team decided that rather than focus on the most experienced nurses and only allow them to learn ECMO, the safer choice was to educate everyone caring for ECMO patients to be a specialist.
Although I was hesitant at first, I was shocked how well the newer nurses picked up the concepts of ECMO and how well they cared for these complex patients. Over the next several months, it was amazing to watch the transformation from a disjointed unit where only a select group of nurses could watch the pumps to staff who seamlessly transitioned from nurse to specialist on a daily basis. The best testament to the training happened in an acute air entrainment situation. In all of my years caring for ECMO patients, I had never actually seen it happen. While placing a central line, air was entrained into the venous drainage cannula and locked the pump. Without preload, the pump stopped. Within seconds, the room was divided into two teams: One team coded the patient, and the other coded the pump. The reactions were seamless and automatic. It was incredible to watch how far this unit had come.
COVID Flipped the EMCO Script
During my first year as an NP, I played a role in the selection of patients for ECMO. In 2021, we had more than 700 referrals for ECMO. I spent hours each day talking to nurses and physicians from outside hospitals, and evaluating patients to see if they would be good ECMO candidates. Frequently, the nurses and physicians were so helpful, kind and concerned. They would give me details about the patient’s family, how many kids they have, or why they think this patient deserves ECMO more than any other patient. But a lot of times, they were just defeated. I would tell them that we don’t know if we’re going to have a bed. They’d say, “Yeah, we know. You’re the ninth hospital we’ve called.” It was just devastating.
When I think about ECMO and this pandemic, and the nurses caring for patients with COVID, I think the difference is that the ECMO nurses hope where others have lost any possibility of hope. It’s so critical to decide on ECMO at the right time - not too early and not too late. ECMO takes that thin line between life and death in the ICU and reduces the chances of mortality. In talking to other nurses who frequently care for ECMO patients, they bring up moral dilemmas and describe these patients as barely alive. “They're only alive because of machines. What are we doing? What is the point of this? Where are we going?” And while I see that frustration again, cutting that pencil thin line between life and death in half, I can’t help but be optimistic. “Optimism that borders on delusion” as one physician described it. But I know that ECMO allows these patients to have hope, where otherwise they would have none.
ECMO and a Wedding
If patients are awake and interactive, it makes the ICU care for COVID so much more enjoyable - but it also makes the losses hard. Unlike the depersonalized intubated patients with COVID, our patients are typically awake and interactive. This means weeks or months of getting to know them and their families despite the patients being unbelievably sick.
My favorite moment so far was when a patient and his fiancée told one of the nurses they wanted to get married. She had been at his bedside every day since he was admitted, and the rest of us had no idea they were waiting to get married. The idea spread rapidly, and soon the staff were planning a hospital wedding to celebrate the couple. We needed it too. It had been months of grueling numbers, tragic losses and no end in sight. Everyone’s energy was channeled into this wedding.
My favorite part of the whole day was walking by the room, an hour before we left the unit for the chapel (crash cart and backup ECMO circuit in tow). There were four nurses in his room getting him dressed for his big day. Several nurses went to buy him a wedding suit, including a shirt that was cut and sutured back together around the ECMO cannula. After the ceremony, we danced through the halls of the hospital playing cheesy songs you would expect to hear at a wedding and walked onto the unit to a dozen nurses throwing rice to celebrate. He even had a sign on the back of his bed that read “Just married.” It’s incredible to think that without ECMO, none of that would have happened. He would never have been able to marry the love of his life.
Looking to the Future
The hardest part for me during the pandemic is having to tell 20 times more people no than I could ever tell yes. ECMO was the last resort for hundreds of patients who never got the chance. While it was horribly stressful and often disheartening, it made me value the times we got to say yes that much more. I started to see our ECMO patients as this treasure. On the day we had a bed and would pick the best candidate, I would hear so much hope in the nurse’s voice, and the excitement that the patient even had a sliver of a chance more than anyone else in their ICU meant the world. The way healthcare has many technological advances, I see ECMO playing a large role in our future healthcare system. But these advances in new technologies mean nothing without nurses’ support. This pandemic has taught me not to underestimate the power of education and hope.
To Learn More About ECMO:
- Visit the website The Institute for Extracorporeal Life Support for ECMO training and development
- Read the article “Transitioning from Perfusionist to Nurse-Driven Team: Crafting ECMO Success”
- Watch the AACN webinar “Extracorporeal Life Support: RN Management of ECMO Patients”
What is your best memory with an ECMO patient?