Organizing ECMO Transport!

Organizing ECMO Transport!The practice of ECMO is unique in critical care medicine.Before the introduction of ECMO in the armamentarium of available technologies in critical care, physicians used to maximize their efforts and pray if nothing more could be added to the patient care, especially when the pathophysiology indicated a rapid decline of the patient's clinical status.Once a physician and the team are trained in the science of ECMO, multiple options open up to keep the patient alive.There starts the conflict between continuing the supramaximal conventional care at the center offering conventional management versus transporting the critically ill patient with falling oxygen saturations with labile blood pressure to the ECMO center where definitive treatment can be offered.As we all know, the journey of ECMO physician starts the moment we are referred a deteriorating patient, struggling between life and death.We went through this phase of difficulty in decision making in the days in the transitional period when transport ECMO was in rudimentary stages in our institute.We know that all the patients who aren't placed on ECMO will not die.With the "Trust" in ECMO, and having known that ECMO could save lives by providing rest to the lungs/heart till the time of recovery, a ray of hope guides the adventurous journey transporting very sick patient all the way from the traditional ICU to a ECMO center by carefully providing the support all the way through.In a country such as India, where the distances are huge, planning critical care transport., especially for long distances, needs learning from established practices from the developed countries, matching the needs in our own circles and adaptation of different methodologies (if needed) to achieve the goal of safe patient transfer.Our patients come from all age groups, starting from neonates to adults.Initiation of ECMO at the center where conventional patient care is provided, and then transferring the patient on ECMO would be ideal considering the patient journey.However, the majority of the ECMO centers may not be able to offer mobile ECMO transfers.Commercial air transport facilities would be available, but the cost of initiation and air transport has to be taken into consideration.In those circumstances, the critically ill patient has to be transported to the ECMO center by providing maximal support to provide gas exchange and maintain cardiac output.The selection of the case for road transfer would make the process difficult.The collaboration between the physicians managing conventional care and the ECMO center is crucial for successful transport.Understanding each other's needs and limitations will help in the optimization of patient care prior to transfer.If any additional investigations are needed to satisfy the decision-making, selection criteria for ECMO, additional measures in changing ventilator settings, sedation, fluid management, inotropic therapy might help in improving patient management.In our experience, we noticed improvement in the patient's clinical status by the time we reached the other city.Once we left the patient in the referring center (in view of the improvement).Following deterioration the next day, we had to go back to get patient for ECMO placement.It would be ideal to bring the patient in the first instance, despite transient improvement, watch the patient in the ECMO center and send them back after recovery, in case they don't need ECMO.I consider critical care transport as an individual skill needing knowledge, experience and expertise, as one has to be well-versed with the deteriorating pathophysiology, skills to adapt to changing patient, road and weather conditions.Preparation, planning and execution are the key to success.Like other scenarios in critical care, proper organization of the "Transport Team" is vital.A team can be defined as a proper group of trained professionals, understanding and supporting each other in times of need.The transport of the critical care patient could be intra-hospital within the city or inter-city.Appropriate plan, medical supplies, crash cart, medications and fluids needed are essential.The equipment should be in perfect working order.Personnel should be well-trained and prepared for the mission.Organizing successful transport to the ECMO center forms the basis for successful ECMO outcomes, provided we can minimize the duration of hypoxia.If a national center for arranging ECMO/critical care transfers could be arranged, that would be the best.Individual referring centers can call the center and request the critical care transport services.In a vast country such as India, a single transport base may be difficult.Capital cities of various cities can establish this model, serving their local needs.There might be a role for properly planned and executed long-distance critical care services by modifying the available services by utilizing rail services.Organizing ideal transport services in any country with varying geological conditions, varying access to healthcare facilities, varying financial resources would be a challenge.It is important to audit our performance periodically to correct any deficiencies and implement changes.By putting minds together, we should be able to plan and organize better-coordinated regional transport centers.