A long way from the mothership

Early!

Mobilising the resources for an ECMO patient takes time. Mobilising a team to travel to Mildura takes even longer. A timely referral can expedite the escalation of the patients care.

Patients this sick often exhaust the capability and comfort levels of regional centres. They are often being managed by the most senior clinician and the referral may have to be relayed by more junior medical staff. Whilst waiting for help to arrive, experienced staff maybe able to provide additional clinical advice to help optimise patient care.

In Victoria, you would call the Victorian ECMO Service (VECMOS) on 1300 832 667 (1300 VECMOS) to establish an ECMO teleconference call with an ECMO Advice Specialist.

Often multiple people are included on this call. These may include but are not limited to: referring clinician, ARV Clinical coordinator, ECMO Advice Specialist/s, Retrieval Physician, +/- CCRN (Critical Care Registered Nurse.)

On initial contact, the referring clinician needs to provide the patients details and vital signs before relaying the pertinent clinical information. This can take a few minutes, so have the information at hand prior to referral. Don’t forget the weight. At 160kg this patient might not even fit on an ambulance stretcher!

It’s important to establish the patient’s suitability for ECMO.

• Are there any contraindications? (e.g multi organ dysfunction, severe sepsis, age, frailty, co-morbidities)
• What investigations and treatment has the patient had to date?
• What has been the patient’s trajectory?
• Current ventilator settings
• Recent pathology, radiology and ABG results
• What central access does the patient have? (Can a femoral CVC be re-sited whilst awaiting the retrieval team?)
• Any infection control concerns? (e.g. has SARS-CoV-2 PCR been performed?)

Patient selection considerations used in Victoria are available on ECMO.ICU:

• Patient selection – V-A ECMO
• Patient selection – V-V ECMO
• ECPR inclusion criteria

Bariatric transfers provide additional layers of complexity.

For morbidly obese patients, dimensions are required to ensure the patient fits on a conventional ambulance stretcher. ARV will provide a bariatric sizing chart to guide measurements. Organising a CPAV (Complex Patient Ambulance Vehicle) for bariatric transfers is convoluted and takes time. Unfortunately, their weight forgoes them travelling via Fixed or Rotary wing. Mildura is one of the furthest hospitals from Melbourne. Routinely we would ideally fly by fixed wing due to their superior speed and range. It’s a long drive in a CPAV!

Timing

Often referrals come through at an antisocial time of day. Fatigue management can influence your decision on how to dispatch your team.  Restrictions on pilot hours, changes in shifts and unacceptable overtime can alter what is the best course of action. In some situations, delaying the transfer to the following morning maybe the best option. If safe to do so.

Infection control

In this post-pandemic world, anyone with respiratory failure has COVID-19 until proven otherwise. This already adds a further layer of complexity to what is already a challenging case.

Currently, in the state there are 5 helicopters. HEMS 1 + 5 are based in Melbourne. HEMS 2 in Traralgon, HEMS 3 in Bendigo and HEMS 4 in Warnambool. They are staffed by a Flight MICA paramedic and crewman. Overnight there are 2 fixed wings available from Essendon. Currently, there is one ARV ambulance staffed with a CCRN and PTO (patient transport officer) until 01:00.

Moving a complex patient like this is rarely done using an ALS (Advanced Life Support) ambulance. Moving a patient on ECMO, a ventilator and 6 infusions brings it’s own challenges if you have nowhere to secure your equipment. CPAVs are a scarce resource scattered across the state. They are staffed by Ambulance attendants to help operate specialized bariatric equipment.

To form the retrieval team you need the following people:

• ECMO team (2 intensivists +/- fellow or Intensivist and ECMO CCRN),
• Retrieval Physician or Senior Registrar,
• Retrieval CCRN, and
• Patient transport officer (PTO).

This is not an exhaustive list but includes important things to remember.

Patient

• secured ETT, lines and devices
• medication (ample to get you to Melbourne, emergency drugs relaxant/sedation/vasopressors)
• fully charged ventilator, infusions and monitor (with external power supply)  

ECMO

• hand crank
• adequate oxygen supply (portable and ambulance)
• multiple clamps
• fully charged console and external power supply

Staff

• empty bladder
• fed and watered

As the pandemic unfolded and the Victorian ECMO service became  established, there was an increasing number of ECMO retrievals.

ECMO centres in Victoria are categorised by VECMOS as follows:

• Level 1/Comprehensive (Initiate, sustain and retrieve VA, VV and ECPR) – The Alfred
• Level 2/Intermediate (Initiate and sustain selected ECMO. May potentially receive patients retrieved by Level 1 centre) – Royal Melbourne Hospital and University Hospital Geelong.
• Level 3/Initiation (Initiate and transfer patient to Alfred Health) – St Vincent’s, Austin, Box Hill and Monash Medical Centre/ Victorian Heart Hospital