My Evolution as an RRT ECMO Specialist: We Are One Team

By Myron L. Norman, BSRT, RRT, CES-A Sep 06, 2023

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A question I am often asked is: "What attracted me to ECMO?" My response is: "the critical illness of the patient at the moment."

A question I am often asked is: "What attracted me to ECMO?" My response is: "the critical illness of the patient at the moment." Since it is difficult to give such a succinct answer, I want to provide insight into my thought processes. We know how hard it is trying to stabilize a patient who is actively dying in front of us and no longer responding sufficiently to anything we did to save them. I remember watching, in awe, as the ECMO team would show up and often rescue a patient at the last moment. They would swoop in, put together this complex-looking machine and tubing, connect the circuit to the patient via the cannulas inserted by the surgeon, and miraculously the patient would look much better. Magic, I thought. I remember telling myself, "I have got to learn to do that!"

Another attraction for me was the realization that as an ECMO specialist (ES), I am part of a relatively small group of medical professionals who are the only ones who can do what they do. I sometimes feel that ESs are like a SWAT team. When everyone is running out of the building, we are called in to rescue the patient. Ever since I attended respiratory therapist (RT) school, I have been drawn to caring for the sickest of the sick. The patients don't get more critical than those who require ECMO. It's like I am pitting my knowledge and abilities against whatever has caused the patients to require this level of care. When the patients recover, are weaned from ECMO and eventually go home to their families, there is satisfaction like no other. As a team, we look at each other and say job well done!

What Is ECMO?

Some of you may be wondering what ECMO means? ECMO stands for extracorporeal membrane oxygenation. ECMO is a very high level of life support often used with patients experiencing pulmonary failure and/or cardiac failure. There are two main types of ECMO therapy: VV ECMO, which means two veins are cannulated for pulmonary support, and VA ECMO, which means a vein and an artery are cannulated to provide pulmonary and hemodynamic support for cardiac compromise.

The ECMO machine has a pump that draws the blood out through the cannula in the vein and sends it through a filter where carbon dioxide is removed and oxygen is added. Then the blood returns to either a vein or an artery. Venous blood is drawn out of the patient but returns into the patient as arterialized blood. This allows the lungs and/or heart to have most of the workload taken away and allow for time to recover. ECMO doesn't "fix" anything; it just buys time for the medical care providers and the patient's body to create the right conditions for a hopeful recovery.

It Truly Takes a Team

When they hear about ECMO, most people immediately think you must be either a perfusionist or a registered nurse (RN) to be an ES. Many people aren't aware that registered respiratory therapists (RRTs) can become ESs as well. Most ECMO programs usually are composed of two, or all three, of these medical disciplines. I was trained to become an ES on a team that consisted of RNs and RRTs caring for complex ECMO patients in the same capacity. Twenty-one years later, I can proudly say this team is still collaborating this way today.

As I expanded my borders and knowledge of ECMO beyond the hospital where I was trained, I encountered a recurring theme that RRTs are not qualified to be ESs. Being an RRT, I felt I was as capable as an RN or a perfusionist. This perception seemed to stem from the opinion that as RRTs, our knowledge base is focused primarily on the lungs with some cardiac added for good measure. Perfusionists, on the other hand, run the cardiopulmonary bypass machine in the cardiac operating room, and nurses' educational training covers all the organ systems of the body. Even though it is used primarily for pulmonary and/or cardiac failure, ECMO supports the entire body. This situation does create a learning curve for RRTs to understand more about the body's other organ systems and some of the normal ECMO lab results, but it is not an insurmountable curve to overcome.

Setting the Standard for Collaborative Care

Realizing that not all ECMO programs used RRTs, and many healthcare professionals felt RTs were not qualified to become ESs, caused me to appreciate the cohesive-centric team where I was trained. One of the standards we tried to exhibit was that RNs and RRTs had the same roles and expectations when caring for an ECMO patient; meaning there was no difference in job description or responsibility. We all functioned in the same capacity. We truly were one team. However, the uniformity of responsibility between roles isn't what made us a team. It was the realization and acceptance that we respected each other's strengths in caring for this complex patient population. The goal with each ECMO patient is to provide the best care possible.

Breaking Down Barriers Through Teaching

As I began my career with an organization providing consulting services to help develop or review ECMO programs, first as contract staff in various hospitals, then as an educator, I heard that same recurring theme about my role. As an RRT, I wasn't qualified to be an ES or teach and precept anyone on how to become an ES. The myth still existed that I knew much less than what the physicians, perfusionists and nurses needed to know to care for these critically ill patients. The common reason was that our formal cardiopulmonary training to become RRTs is focused primarily on the pulmonary system, and we don't typically have formal schooling to encompass all of the body systems.

However, I have found throughout my career as an educator that nurses usually understand different organ systems and lab results and how the body responds to ECMO treatment but not necessarily the ECMO circuit system. RTs understand the ECMO circuit system, tubing, pressures and flows because they work with ventilators every day. RNs and RRTs both have learning curves; their starting points are just different.

When I am precepting a new ES, I let my knowledge and understanding come through during the process of helping the ES in-training understand how to use the ECMO system and care for the patient. This process is especially apparent when I can discuss in depth how the different organ systems are affected by the ECMO system and how to respond and treat patients on ECMO. Sharing knowledge where you can is something I encourage others to do, regardless of their roles.

Thankful for Multidisciplinary Relationships

Becoming an ES has pushed me out of my comfort zone and requires me to learn and maintain competence in many things, which strengthened my knowledge. I was nurtured and grew as an ES on a team where the RNs and RRT ESs collaborated as a team. While my focus has been on helping RRTs improve their knowledge and ability as ESs and encouraging them to pursue this rewarding career, I also am trying to change the perception about RRTs to improve interdisciplinary collaboration. I am collaborating with a physical therapist (PT) to create an ECMO training course for PTs and occupational therapists (OTs). This course is designed to increase their knowledge about and comfort with ECMO during their mobility sessions. I am a huge advocate for patients being awake and participating in early mobility.

An ECMO team, which is part of a unit care team, cares for ECMO patients. All members of the ECMO team, which includes the family, have a very important part to play in the care and recovery of the patient. So much evidence points to the benefit to the patient, family, staff and even the hospital of liberating patients from ECMO as soon as possible. A crucial part of recovery depends on how the patient is managed before, during and after ECMO. Instead of being focused on whether we are an RN or RRT, let's focus on the patient's needs and be a cohesive team working together to provide the best care we can, using each discipline's expertise.

The team that I am part of strives to provide collaborative education to all staff, advocating a team approach to patient care.

How does your team create a collaborative environment for patient care?