ER Doctors Are Bringing Patients Back From the Dead

Using a machine from the 1950s.

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Mar 30 2017, 12:00pm

A sincere thank you is all Conrad said one week after being brought to Sharp Memorial Hospital in San Diego for a uniformly fatal allergic reaction to peanuts. He would not have uttered these two words had he been brought to virtually any other emergency department in the United States. At almost every other ER, Conrad would have certainly died.

The summer of 2016, Conrad, a 28-year-old youth Jiu Jitsu instructor from San Diego, was having a regular family dinner at a local Chinese restaurant. He had lived his whole life with a severe allergy to peanuts, and thus carried an epinephrine injection with him at all times. That night he avoided the traditional Chinese dishes, knowing they had been simmering in peanut oil for hours. But he reached for a couple of steamed dumplings, assuming they were peanut-free. After several minutes he knew something was terribly wrong.

What started as a feeling of anxiousness and trouble breathing rapidly progressed; soon he was unconscious on the floor. The dumplings had been full of peanuts, and were now in his gut, which was releasing a constant flood of allergic hormones. Paramedics arrived and immediately intubated Conrad, putting him on a breathing machine.

According the doctor who treated Conrad in the ER, Andrew Eads, Conrad's body was so starved of oxygen by the time he arrived at the hospital that he looked "dead and purple." Despite maximal medical treatment, massive doses of epinephrine, 100 percent pure oxygen from the breathing machine, and enormous doses of steroids, Conrad's lungs were swollen shut and unable to move any air.

"His lungs were so tight he couldn't exhale. I put my full body weight on his chest and could barely squeeze anything out," Eads remembers. Conrad's lungs were too inflamed, too constricted, and too swollen to sustain any life. The standard strategy would have been to keep giving steroids and epinephrine, increase the pressure of the ventilation machine, add some magnesium and hope that eventually his lungs would loosen up before they popped. But in Conrad's case, the dumplings still had to traverse 25 feet of intestine. He wasn't going to improve any time soon.

"He would not have lasted another 20 minutes," Eads says. It was at that point that Eads, with the help of critical care physician Kevin Shaw, placed him on cardiopulmonary bypass, aka Extracorporeal Membrane Oxygenation, or ECMO (pronounced "Eck-mo") for short. It saved Conrad's life: He walked out of the hospital weeks later like nothing had happened, apart from a scar on his neck.

Until 2010, CPR was an emergency physician's only means of extending life. But the use of ECMO in select patients has become a new bridge to life-saving interventions. ECMO in theory is very simple and builds off the physiology of CPR: In CPR we take over the three main functions of the heart and lungs—oxygenate blood, remove carbon dioxide from blood, and pump the blood to the rest of the body. During CPR, a beating heart is simulated by chest thrusts at 100 times per minute, and air is passed through the lungs by a breathing tube and oxygen bag instead of the patient's own diaphragm. CPR, with its first successful documented case in 1903, will continue to save lives, but will always remain a crude replacement for a functional heart and pair of lungs.

In ECMO, large tubes are inserted into the great vessels of the groin or neck to withdraw the entire circulating blood volume. The blood is then passed between a membrane that transfers oxygen and carbon dioxide, warmed, and pumped back into the patient. Unlike the physically demanding chests thrusts and loud sounds of cracking ribs and a creaking gurney with CPR, ECMO is quiet, featuring only the elegant hum of the pressure pump.

ECMO was initially conceived in the 1950s to use on premature infants with fatally immature lungs, and like most 1950s machines, the contraption took up nearly a whole room. It was further refined in subsequent decades and the machine continued to decrease in size, but in adults was reserved for planned procedures such as open heart surgery in sterile, quiet, and controlled operating rooms. Other than the size, the underlying indication of ECMO has changed very little: If the heart or lungs are not working, get machines to take over.

But nobody ever thought to bring ECMO from the OR down to the ER, where hearts and lungs stop working all the time. Advances in materials technology have decreased the size of ECMO machines to that of a boombox, however the real leap came in the form of human pioneering. Aside from scattered reports in Japan, nobody had ever thought of this—using technology that has existed since the 1950s in an often malodorous, loud, and chaotic ER. Not until Joe Bellezzo and Zack Shinar.

The concept began in 2010 at Sharp Memorial Hospital, where Bellezzo was working in the ER. "I was in the doctor's dining room," he recounts, "and had just watched a 50-year-old woman die from a pulmonary embolism [blood clot to the lungs], who I did everything I could for. Over two hours, I painfully watched her arrive with just shortness of breath, to decreasing blood pressure, and eventually death. In the dining room was Dr. Walter Dembitsky—an older, well-established and world-renowned cardiothoracic surgeon. I felt terrible [about the case], but Dr. Dembitsky got pissed at me and said, 'Why the fuck did you not put her on ECMO?!' He grabbed me by the lapel, marched me up to the cardiothoracic operating room, pointed to two ECMO machines that were sitting there…and said, 'You can save lives with these.'"

"I thought he was off his rocker," Bellezzo says. "But I told [Shinar] about it, and we started to talk it out. Maybe a month later, [Shinar] decided to give a lecture about how we could possibly use ECMO. None of us had ever done it—touched a machine, seen a patient on it, or even seen a case, nothing."

On the very same day as Shinar's lecture, Ralph, a 59-year-old male, arrived in the ER in cardiac arrest. With Shinar in charge and Bellezzo assisting, they administered CPR and the cardiac life support algorithm ER doctors give to every patient who's heart has stopped: calcium, bicarbonate, saline, glucose, epinephrine, and electrical defibrillation when indicated. When these didn't work and when Ralph remained dead, and at a point when every ER physician in this country would have looked to the clock for the time of death, Shinar turned to Bellezzo and said, "We gotta put him on ECMO."

"I don't even know how to do that," was Bellezzo's response, but with no other option but to quit, they called down the ECMO team from the Surgical Intensive Care Unit. The ECMO team, a 24/7 and 365-day-a-year constant presence at Sharp Memorial Hospital, consists of two nurses trained to emergently run the complicated machines. They are the crucial link at Sharp that make ECMO in the ER possible.

Shinar and Bellezzo successfully placed Ralph on ECMO, and rushed him to the cardiac catheterization lab, where a cardiologist was able to stent the blockage that caused Ralph's heart attack. Ralph not only lived, but walked out of the hospital nine days later like nothing had happened.

Shinar, Ralph, and Bellezzo three months after his cardiac arrest. Image courtesy of Joe Bellezzo

From that fateful day in 2010, Bellezzo and Shinar went on to found the world's first emergency department ECMO program. They created EDECMO.org, an organization dedicated to the research and worldwide education of ECMO in the emergency department. Every year they host a conference called REANIMATE, aptly named, as the Sharp team has gone far beyond simply resuscitating patients—for all intents and purposes, they are bringing them back to life.

As much as we would like to bring everyone back from the dead, ECMO is not for everyone. Multiple criteria exist for it to even be considered. Due to limited resources and outcome predictions, deciding to put a patient on ECMO is the hardest aspect of the entire process, Bellezzo says. Patients need to possess a meaningful quality of life ahead of them to endure the rigors, stress, and potential complications of ECMO. It doesn't make sense to put an 80-year-old with dementia on ECMO; the likelihood of survival is too low.

Regarding the chances of ECMO being used in a hospital near you: According to an August 2016 study, only 14 hospitals in the United States regularly offer ECMO in the emergency department, with a further 22 having the capability to provide it. As it stands, ECMO is far beyond the standard of care, but with REANIMATE and EDECMO.org, Shinar and Bellezzo are attempting to change that standard. At these conferences, physicians and nurses become familiar with machines they have never used, and perfect the techniques needed to insert half-inch tubes into the vessels of the neck and groin. Within ten or 15 years, ECMO may start making regular appearances in every American ER.

In France, meanwhile, where emergency physicians also ride in ambulances, they are really pushing ECMO boundaries: French physicians provide ECMO in the field—one even placed a patient on ECMO in the Louvre in 2015. This, we ER doctors like to think, brings truth to Sir William Osler's famous quote: The practice of medicine is an art, not a trade.

Darragh O'Carroll is an emergency physician in Hawaii.

Update 3/30/17: A previous version of this story misspelled Joe Bellezzo's name. It's Bellezzo, not Bellezo.

Update 4/7/17: The story has been updated to include Kevin Shaw's involvement.

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