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Every time I read about ECMO, the stories are saturated with weird comments by doctors and hospital officials about its “proper use”, whether they are doing the

• ceejayoz 5y ago
  Cost isn't the only consideration; staffing is also important. ECMO is extremely high-touch (1:1 nursing recommended, and some patients may need 2:1), even compared to other ICU procedures; given a primary concern during the pandemic was running out of ICU capacity, a bunch of patients on ECMO can cause you to get to that point much more rapidly.
  • JshWright 5y ago
    Staffing is a component of the cost.
    • mrkstu 5y ago
      It’s also an absolute availability issue. A hospital has, in the near to intermediate time horizon, the staff that it has. So dedicating staff in such ratios make them unavailable to other patients, so triage considerations come into play.
    • ceejayoz 5y ago
      Staffing and cost are related, but there are staffing requirements that no amount of money thrown at them can fix.
    • munificent 5y ago
      Nurses are not an infinitely fungible commodity.
      • JshWright 5y ago
        No, but a significant cause of current staffing shortages are stagnant wages (especially for non-travel nursing roles). Hospitals paying decent wages to full-time/permanent staff would go a long way towards solving staffing shortages.
• ausbah 5y ago
  not trying to play doctor here, but a quick skim through the wikipedia article shows a high risk for developing neurological issues, infection, and blood related ailments I imagine, and I hope someone with more knowledge can add on or correct me, that medicinal professionals are generally reluctant to use ECMO for extended periods due to the aforementioned issues. I personally know if my odds of waking up brain dead from a procedure were 50-50%, I wouldn't take that risk. so I wonder if doctors in this case saw a corresponding decrease in such risks? https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation?wprov=sfti1 https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...
  • leereeves 5y ago
    I'm not a doctor either, but doesn't chemo have similarly high risks of serious side effects? When the odds of death are close to 100% otherwise, a treatment that improves those odds to 50% doesn't sound so bad.
    • kingkawn 5y ago
      This is a serious decision, not just between 100% death and 50%, but a significantly worse death for the other half of people than the original certain one. Take the final period of a person’s life from them and their family for a devastating treatment that doesn’t help and then see how simple of a choice it feels.
    • JohnBooty 5y ago
      My understanding is that hesitation to employ ECMO isn't about the risk of failure. It's not like chemo or dialysis where you can live some kind of meaningful life while the treatment has an X% chance of buying you Y years. It's extremely labor intensive. Another commenter mentioned 1:1 fulltime nurse care. If true, that means multiple fulltime employees, working in shifts, per ECMO patient. Given finite medical resources (doctors, nurses, beds, ECMO machines) we would like to make sure we're employing this only for patients who have a hope of recovering afterward. In that sense it is similar to other "extreme measures" like ventilators and so on. We can sometimes keep somebody alive in a totally nonviable state for an extended amount of time after heart and/or lung failure, but if there's zero chance for recovery it just doesn't make sense from an ethical or practical standpoint. (edit - when I say "we" I mean society. not "we" as in "we medical professionals." I am not a medical professional!)
• carbocation 5y ago
  ECMO is high risk for the patient, especially venoarterial (VA) ECMO which is probably not what is being described in this article. Venovenous (VV) ECMO doesn't dump blood into the arterial tree, so your risk of stroke or other arterial thrombotic complications is much lower. You still risk infection and venous clotting (and therefore the risks of iatrogenic anticoagulation), but I think most of us would accept those risks. From a systems standpoint, the use of mechanical support usually makes sense in the context of being a bridge to somewhere that is not in-hospital, even in the event of non-recovery. At least where I practice, we want to be able to offer a durable device, or transplantation, if you don't recover. If you live in a place where the health system would not offer transplantation (e.g., because of some risk factor like advanced age), then offering ECMO makes less sense because it is not a bridge to anywhere, particularly for VA ECMO. For VV ECMO, I think there has long been a recognition that people can do OK for an extended period of time (in contrast to VA ECMO, where the risks are higher and there are also destination therapies like ventricular assist devices). And if you're waiting for a lung transplant vs recovery, you may be waiting for quite awhile. To this end, there are special catheters for VV ECMO that facilitate mobility so you can retain some degree of strength and mobility while on ECMO (e.g., https://www.getinge.com/int/product-catalog/avalon-elite-bi-caval-dual-lumen-catheter/ https://www.getinge.com/int/product-catalog/avalon-elite-bi-... ). I'm closer to VA ECMO than to VV ECMO (but do neither); still, your comments ring more true for me about VV ECMO (which again I think is the subject of this article), whereas I think that patient risk + superior bridging/destination strategies really do dominate the VA ECMO discussion.
  • jessriedel 5y ago
    Thank you for this reply. Highly informative. > whereas I think that patient risk + superior bridging/destination strategies really do dominate the VA ECMO discussion. Is the idea here that when doctors are considering VA ECMO for a patient there is usually some non-trivial chance that the patient survives without it? In that case the choice, I guess, is between higher survival with more complications (VV ECMO) and lower survival with fewer complications (no ECMO)?
    • carbocation 5y ago
• kingkawn 5y ago
  The negative side effects are not to be taken lightly, especially if they cause profound suffering prior to a patient’s death or severe lifelong morbidity for a survivor. Yes, there are amazing uses of the technology, but the doctors who refer to proper use are speaking from a place of having seen the improper use.
• andi999 5y ago
  Some countries do not perform hemicorporectomy, since they think survival would not be worth it.
• kxyvr 5y ago
  Outside of the other comments here, I would also suggest considering the expected outcomes rather than just whether or not someone will live and die. For example, if someone spends a month on ECMO and the end result is that they're neurologically devastated, require a feeding tube, tracheostomy, and get discharged to an LTAC, was it worth it? If someone can never have a conversation again, or hold they're children, or read a book, was it worth it? If someone is likely to die, is it worth it to break their ribs or cover them in their own blood and fluid when they code? Given how sick someone is when they're put on ECMO, these are all realistic and likely outcomes. And, look, this is a value choice that families have to make, but also one that most have not considered before getting sick and don't really want to consider when they're thrown into that situation. Physicians know about these likely outcomes, so it affects their opinion about its use. As a brief aside, if anyone does end up in this situation, it's stressful and I'm sorry that you're going through this. Really. If I could offer one unsolicited suggestion, it would be to discuss the possible and likely outcomes with your physician, beyond life and death, so that you can make an informed decision that's best for your family.
  • vkou 5y ago
    Not to mention the costs. Medical resources are limited, and in a country where we are chronically under treating people, it makes no sense to torture someone with an ECMO for a month, only for them to 'recover' to the state mentioned above. That money/medical effort could have been used to save/significantly improve the lives of dozens of people, instead of prolonging the death of one. It all comes out of an insurance pool, it's not like people are bearing ECMO costs out-of-pocket. It all comes out of the same labour pool, when you've got your entire medical staff put on hopeless cases, there are people who could be helped who are being denied treatment.
    • nradov 5y ago
      We are both chronically under treating some patients and over treating others. Over treatment is a leading cause of iatrogenic harm. Some providers default to aggressive treatment whether due to a sincere belief that it's best for the patient, or to satisfy patient requests, or to make more money. But evidence based medicine guidelines indicate that it's often best to do nothing beyond active monitoring of the patient's condition. https://dx.doi.org/10.1371%2Fjournal.pone.0181970 https://dx.doi.org/10.1371%2Fjournal.pone.0181970 Ideally we should be allocating limited medical resources based on formulas that maximize overall benefit as quantified by quality-adjusted life years (QALY). But it's politically difficult to set rational policies around rationing care without triggering toxic disputes about "death panels" and "killing grandma".
• meroes 5y ago
  What do the survivors deal with though? I recently had an injury that required surgery and occupational therapy. My entire limb was a sad, useless appendage for months mostly due to immobility and how it reacted to pain. I can’t imagine the mountain one must surmount to get back to even 25% of their pre illness self. I was down to 15% use by the time my OT started. And 6 months later it still is a daily task to keep improving (much better now though). It must take an incredible toll and on already sick body.
• cat_plus_plus 5y ago
  I think the right thing to do for the time being is to consider prolonged use of ECMO as a research practice where not everyone is accepted but those accepted taken care off as long as they are conscious or have a decent chance of regaining consciousness and making their own informed decision. Costs of doing so are part of research budget that determines how many patients can be included. Not providing care to everyone is ethical so long as we don't know if the care is going to help anyway. In turn, research can determine - Exactly what kind of patients are most likely to recover after prolonged use of current ECMO machines - Potential ways to bring equipment and nursing costs down while preserving most of effectiveness. - Ways to wean the patient off intensive care long term. For example, the very first genetically modified pig heart transplant resulted in 2 months conscious survival. Even if animal transplants never become a long term solution, they could prove more cost and medically effective than ECMOs to buy time for own organ recovery or a human transplant.
• Fomite 5y ago
  A lot of my infection control colleagues are rightly terrified of keeping people on ECMO or mechanical ventilation due to infection risk, that are extremely hard to treat. This was especially acute during the early phase of the pandemic, when the combination of the intensity of care COVID patients required + the PPE shortage meant some compromises that they'd really prefer not to make.