10 ms·

How ECMO is redefining death

175 points by _xerces_ 2y ago

mareth2 2y ago
ECMO saved my granddaughter’s life 12 years ago at John Hopkins. She was born on Christmas Eve and weighed over 8lbs but turned “blue” within 30 mins of birth. She was immediately put on ventilator- dx with pediatric pulmonary hypertension. Later placed on ECMO when condition deteriorated and it saved her life. She spent months in hospital but is now a very active 12 y/o with no cognitive deficits. She is now on only one heart medication and recent heart catheter showed slight improvements. It’s my understanding she will always be on a heart medication. She came home from the hospital with a j-tube and was quite a struggle to get her to eat food or take a bottle as she never had a bottle or breast for months. It was amazing how articulate she was at a young age and how active as she had been in a induced comma for a long time.She will not be able to participate in competitive sports but can enjoy some sports for fun. She is on level at school. ECMO and the team including the surgeon who came in during the night to make the incision will never be forgotten. I still remember the team pushing the machine down the hall towards her room as a doctor carefully explained the ECMO. Not everyone is as fortunate as our “Warrior Princess” as she was in the right place at right time where the ECMO was readily available in Baltimore's John Hopkins.Margaret Evans
PaulHoule 2y ago
See https://archive.ph/0GP4F https://archive.ph/0GP4F
captainkrtek 2y ago
Another real world story on the usage of ECMO https://archive.ph/TZ90v https://archive.ph/TZ90v . A snowshoer got lost around Mt. Rainier, fell, and had to be rescued. He was hypothermic and went into cardiac arrest, with not a high probability to survive, saved by ECMO and had a full recovery.
idontwantthis 2y ago
This is definitely in the “nice problems to have” ethics pile.
- OJFord 2y ago
  What? In the sense that better to have that problem than just already dead because ECMO doesn't exist, you mean? Otherwise I can't think of any way it's at all nice, and that applies to any dilemma - you can always say 'oh well nice to have the option, better than only the bad lemma'!
  - idontwantthis 2y ago
    I mean that countless people going forward will be saved by this. Some people will become ICU bound walking corpses. It’s an incredible technology that will have profound benefits for humanity.
jprete 2y ago
ECMO is a miracle, but can also lead to some of the saddest situations imaginable: "Without ECMO, she would die. But owing to the complexity of the machine and its attendant risks—catastrophic bleeding, stroke, infection, malfunction—she couldn’t leave [the ICU]. She was waiting, stuck in a kind of limbo between life and death."
- MikeTheGreat 2y ago
  To be fair that pretty much describes all patient visits to the ICU. You're not there because things are fine and you'll be going home soon, you're there because you're on death's door and the hospital folks want to keep you on this side of it.
  - crote 2y ago
    The difference is that most other ICU patients are there with an (albeit slim) chance of recovery. Their body just needs time to heal, and the ICU provides the support necessary to do that. 75% of ICU patients are discharged from the hospital alive, and those who die often do so within the first few weeks. On the other hand, it seems some ECMO patients have zero chance of recovery. Their own organs have failed and aren't coming back, and a transplant doesn't seem to be an option. Sooner or later they will die in that room, most likely due to complications.
    - kelseydh 2y ago
      It really seems similar to dialysis, except more expensive. As technology develops and cheaper devices can be made we can democratize access to these lifesaving devices. It's in the interests of both you and I to democratize access to technologies like ECMO.
      - nradov 2y ago
        I'm not convinced that is in my interest. Personally if I'm in a condition where I need ECMO and don't have a good chance to recover with a high quality of life then I'd rather just check out. (My preference only, not a choice that I want to impose on other patients.) While this technology is amazing, at a societal level I am skeptical whether widespread use is the right way to expend our limited resources. In the USA we could save a lot more life years by diverting some funding away from advanced life support and towards fixing our appalling maternal mortality rate. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021...
lozenge 2y ago
Great article, did New Yorker abandon its rambling house style?
drxzcl 2y ago
Not to downplay the dilemmas we face today, it seems to me that the main problem is that the machine is too expensive, too complicated and too large to serve as a permanent heart/lung replacement. We have an excellent record of making machines smaller, cheaper and simpler to operate. This machine will be the pacemaker of the future.
- sxg 2y ago
  That's definitely not the main problem. Risk of intracranial hemorrhage/strokes and other complications make it problematic.
  - saurik 2y ago
    But that isn't the problem from the article--the ethical issue of how to deal with a ton of people who are being kept alive on a "bridge to nowhere" when the machines might could be used in the interim to save many more people--as if you have an intracranial hemorrhage you are going to start down the road to actually dying. (And the article also talks about attempts to improve the bleeding problem anyway.)
    - toth 2y ago
      To me it sounded like part of the problem is that people on ECMO cannot leave the ICU because at any moment they might have a complication that requires immediate emergency care. So it's not enough to make them smaller and cheaper, they also have to be made much less prone to these complications. I am sure that will happen in time, but I am also sure we'll be able to grow people new lungs in time
      - FireBeyond 2y ago
        Critical care paramedic: that's very much the bigger issue. Some life flight helicopters are being fitted for ECMO and there is NOT much space in a helicopter, once you fit in two providers, a patient on a gurney and care equipment (most HEMS units are Bell 429s and EC/H-135s - MSP uses much larger AW-139s). https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.jpg https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.j... shows the working space on a -135. Note that access to most of the patient is heavily restricted - only chest and head, really. Still, to be clear, we are not really at the 'portable' stage either. There's about 65lb of equipment needed for an ECMO patient just for the ECMO itself, beyond other things like Lifepaks for monitoring.
FuriouslyAdrift 2y ago
ECMO is a last resort type treatment that has common life altering side effects.
- sithadmin 2y ago
  Yep. A good friend of mine who is a perfusionist (a relatively obscure midlevel med tech role focused on ECMO/CPB operations) has made it clear they would rather just be allowed to die than be subjected to either. The majority of cases they're involved with, but most especially the ECMO cases, per their account, are associated with what seems like unnecessary suffering pending death. Their opinion is that in most cases, it's probably not worth the extreme cost and effort, and that tracking 'survival' as the criteria for success is misguided given poor quality of life afterwards, and usually death related to long-term side effects/complications. They admit that their opinion may be clouded by the fact that they've self-selected into working in hospitals that are the most likely to take 'hopeless' cases, though.
  - FireBeyond 2y ago
    I'm a paramedic, and in between seeing quality of life issues post resuscitation, ongoing care challenges and, unfortunately, the state of some skilled nursing and rehab facilities, myself, and I would say a "very very large percentage" of my peers are absolutely on the same page. Unless full recovery with no to minimal deficits is likely, not so much.
  - Workaccount2 2y ago
    I have heard the sentiment before that ICU doctors would rather die than go through the ICU. Couple this with PTSD being a common side effect from ICU care and it starts to make a picture that maybe death is just the way to go.
    - jessriedel 2y ago
      No. This is not at all a representative opinion among ICU docs.
carterschonwald 2y ago
My niece was on Ecmo several years ago after a serious accident. She’s applying to university now. That’s what any non end of life treatment strives to achieve.
mezentius 2y ago
I fail to see how this is, as one specialist puts it, a “profound ethical dilemma," and not simply a temporary and embarrassing misalignment of resources. If you can prevent people from dying—and enable them to live meaningful, sentient lives despite being tethered to a device—then the solution is clear: scale up production while making the devices smaller and cheaper, and in the meantime seek out alternative long-term facilities for palliative care to avoid occupying hospital beds. The fact that the article frames the problem as "we have this fear of letting people die"—instead of a difficult but solvable problem of research, economy, logistics—seems to me emblematic of a certain dead-end, anti-growth mindset that pervades much of supposedly humanistic writing from the NYer. So what if this is "a bridge to nowhere?" So is life! And in the end, we are all, in our own ways, waiting for time to run out, tethered to something immovable.
- feoren 2y ago
  It absolutely boggles my mind that this is such a controversial viewpoint. We're talking about a machine that can keep people not just alive, but awake, talking, and riding an exercise bike, without working lungs or a heart. It's an insane, miraculous treatment, and extremely strong evidence that death is something we can conquer. And people come along and just downvote comments like yours, with no explanation at all, because it's so deeply engrained in their brains they they and everyone they love simply must die, and everyone who believes otherwise must be naive and stupid. Because death is this magical, spiritual, special problem unlike any other problem humanity has ever faced: the one thing we will never be able to solve? It absolutely is a dead-end, anti-growth mindset, and I don't understand it. Why is everyone so in love with death?
  - jprival 2y ago
    It’s not a particularly fair accounting of the framing of the article, which also profiles people who are working precisely on making the technology more practical and portable and ends on a hopeful note. For the time being it’s a high maintenance way to keep people alive, though, so the ethical dilemmas of resource allocation are real.
- DSMan195276 2y ago
samus 2y ago
It reminds me of the situation people used to face when they got Polio. Often, they got stuck in an iron lung for a while and quite a few also never ever recovered lung function, meaning they were stuck for life as well.
skerit 2y ago
"A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U." The only ethical problem I see is other people deciding what life is worth living.
- margalabargala 2y ago
  Fully agree. They have this case study later in the article: > Around a decade ago, a teenager who couldn’t be saved was admitted to a New England hospital. Like Shania Arms, he had cystic fibrosis. A previous lung transplant was failing, and his only hope was another transplant. He was put on ecmo while he waited. Two months later, doctors discovered that he had developed an incurable cancer. Now there was no way for him to leave the I.C.U. His lungs were beyond recovery, and the cancer made him ineligible for transplant. He was caught on a bridge to nowhere. > Some members of the medical team thought that ecmo should be stopped. Transplant was no longer possible, and ecmo machines were scarce. As long as the patient was on the machine, it couldn’t be used to save someone else. It’s also expensive; according to a 2023 study, the median hospitalization charge for covid patients on ecmo was around eight hundred and seventy thousand dollars, and prolonged cases can exceed several million. These resources might be needed to help other patients, and the boy couldn’t live in the I.C.U. indefinitely. > But others on the team disagreed. “He was texting with his friends,” Robert Truog, a pediatrician and bioethicist who was involved with and wrote about the case in The Lancet, said. He was spending time with family, and doing homework online. Because he could be awake on ecmo, he could still engage in activities that were meaningful. Situations like this represent a “profound ethical dilemma,” Raghu Seethala, an intensivist and ecmo specialist at Brigham and Women’s Hospital, told me. “The technology is ahead of the ethics,” another expert said. The technology isn't "ahead of the ethics" as the one quote indicates. This is a simple case of some people apparently advocating for killing a living, conscious, interacting-with-the-world teenager because he wouldn't just hurry up and die, and they want to use his resources for something else. I bet those same people would learn that over 80% of people aged 70-75 reside in a home they own, and immediately come up with a modest proposal for how to solve the housing crisis.
  - 2y ago
feoren 2y ago
"The overarching problem here is that we have this fear of letting people die" This feels like a crazy thing to hear a physician say. Our acceptance of death as inevitable is a learned helplessness. Modern medicine is not even 100 years old by some accounts, and every new decade brings new "miraculous" treatments that naysayers called completely unrealistic before. There's no reason to believe that humanity will need to accept death as inevitable forever. Any theory of medicine that is based on accepting that people die is dooming itself to a primitive, barbaric existence. The ethical dilemma goes away if these machines become more portable and 100x cheaper, a transformation we've seen many times. From keeping a cat alive for 30 minutes in 1934 to humans in 1952 to days in 1971 to months/years in the 2010s-2020s to ... what, decades? Centuries? These people are having conversations and we're saying "well we should let them die because death is a part of life" -- no, it clearly doesn't have to be. Yes, there are cost concerns, triage concerns and quality of life concerns, but those are engineering problems that we know we could dramatically improve if we actually invested significantly in this technology. I do not accept that we should not be afraid of "letting people die" -- let's be fucking terrified of it and do everything we can to stop it, please. Because everything we've seen from medicine over the last 100 years indicates that we can. And to those who say that death must be a part of life or (insert societal problem with shaky justification here) will happen, I ask: what if the situation were reversed? What if everyone lived forever and we were facing overcrowding or whatever -- would your solution be to kill everyone nearing 100 years of age?
- FireBeyond 2y ago
  I don't think it's so much that we kill people. It's that we let them die. If we are truly, brutally honest with ourselves (and overcoming denial, social, religious, whatever conditioning here is a huge struggle), much of the time, the efforts we put in to keeping loved ones alive is really often more about us than it is about them. The elderly (and I'm generalizing, I realize) are far more accepting of death. It's easier to accept that when you feel you have lived a full and happy life. Contrarily, that full and happy life often involves having the presence of loved ones, who are NOT ready to accept that their life will be - or rather, will feel - less full and happy without that person. Even just simple denial is a huge thing. One of my first experiences in emergency medicine was an older gentleman, family patriarch. The rest of his extended family had been able to gather at the hospital while he was in and out of arrest. A provider and support person went to talk to the extended family, who was adamant about following his son, the 'number two patriarch', and his steadfast insistence, "He is a good strong Christian man, and he is going to be okay." (I say this not to mock Christians, to be clear, and also to be clear, he didn't mean in the "eternal life" sense, he and the family truly believed almost that divine intervention was going to take care of things). After some discussion on this, a decision was made to bring the son into the ER where we were working on his father. Seeing the hopelessness and futility, seeing his father the shadow of the man he knew, and all of that assorted detail was no doubt traumatic, but it also made it viscerally real to his son. No matter the concerted efforts of nearly 10 medical professionals, drugs, defibrillation, ventilation, we were not going to be able to keep his father alive, and there was not going to be any divine intervention. He watched this silently for a few moments, and then asked us to discontinue CPR and if his father's organs were suitable for donation. My heart broke for him. But this is a struggle we have not figured out, recently. We had it figured out, historically, by necessity, but we are complacent now. Leaving aside the separate issue of healthcare costs, you can still look at the ratios: In the US, on average we spend more on healthcare keeping someone alive for the last year of their life than we do on the previous decade. And we spend more on that decade than we do on the rest of their life. Some of which seems obvious, given youth, but nonetheless.
ok_dad 2y ago
I only wish the technology were better ten years ago when my father in law passed away. He was on one of these types of machines, but only after he had surgery and his heart and lungs were already failing for days and his body was weak. If they could have put him on the best and newest machine of today right away, then his body could have recovered a bit before they had to operate to fix his heart valve, which was faulty. I do have to say, at the end when we visited him before they turned the machine off, it was absolutely a horror scene with huge clear tubes with blood flowing through them and the machine was fully clear as well, I assume to let staff catch any clotting early. When they turned off the machine I almost couldn’t help but look at the machine and the blood filled tubing, knowing that my father in law was given a second chance by it even though it failed. I used to have nightmares about the scene I saw there, but now I think of how great it is that we can replace some of the most important organs with machines, even if it’s still limited to hospitals. Morally, we should advance this tech as fast as possible so maybe next people can use these in their homes, or as a backpack or something, then on to artificial organs inside the body. The people going on these machines today are pioneers and the things we learn today will help other down the line even better.
- squigz 2y ago
  > I used to have nightmares about the scene I saw there, but now I think of how great it is So many people are not able to get over the grief (or fear, or guilt, or a hundred other emotions) that are usually associated with this sort of equipment, so they're forever seen as a sort of necessary evil - perhaps similar to military technology: something we know we have to have and have to develop, but not something we want to use, or embrace. I wonder if more people looked at these technologies and their potential applications with a bit more optimism, how things might advance.
  - ok_dad 2y ago
    The only reason I got over it was I worked at a medical device assembly factory and saw firsthand how amazing it was that hundreds of people worked together to design test and build life saving devices. I stopped caring about the blood and started rooting for miniaturization, like how computers my mother used were in rooms and today everything has a computer in it. It’s hard though because our natural and trained response is to be grossed out.
daedrdev 2y ago
There is some discussion about the long tail of patients who don't get better, but from the article, this machine seems like it has lead to some incredible outcomes. Better respiratory illness recovery for extreme cases, better ability to recover from some cardiac arrests, etc. Additionally, for most long term patients, the reason they exist on the machine is because a lack of organs for transplant. There is little hope for more organs now, but in the future modified pig organs seem like a possibility for people that could really transform the ability to save peoples lives. Like it is nice that we can have ethics questions about this machine, and hopefully it can give some terminal patients the chance to find their own peace.
xkbarkar 2y ago
I feel the article makes ECMO sounds like a viable common treatment for lung ailments. I have personal experience with ECMO. Disclaimer: I have no medical training. But I have had two loved ones in ECMO in my life. An adult age 48 and a premature infant that weighed a little over 600 grams at birth. The adult died after a very successful month in ECMO during routine change of tubes. Bled to death after a ruptured artery. The infant survived and is thriving today. ECMO is highly specialised, very expensive, incredibly intrusive and also requires large amounts of blood plasma. Blood plasma is not an abundant resource. Just the cost is almost twice that of a standard, expensive cancer treatment. "The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD". https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A%20The%20mean%20estimated%20cost,range%3A%2034%2C121%2D154%2C817 https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A...). Cancer treatment cost example https://www.asbestos.com/featured-stories/high-cost-of-cancer-treatment/#:~:text=At%20an%20average%20total%20of,for%20other%20common%20health%20conditions https://www.asbestos.com/featured-stories/high-cost-of-cance.... So adding to the dangers of using ECMO it is also very very costly. It doesn't make a lot of sense to promote ECMO as casually as this article does.
- huitzitziltzin 2y ago
  Hello - it's your friendly neighborhood health economist (and I have worked on a topic adjacent to ECMO machines). ECMO is unambiguously cost effective (even at US prices!) for the infant. (I'm not defending US prices - needless to say if anything is cost effective at US prices it's passed the hardest cost effectiveness test.) It's also cost effective (even at US prices) for the older patient. Honestly the cited figure of $213,000 is nothing compared to the value of a statistical life (for the infant) or a bit under half of one (for the adult) There should be more of these machines and they should be in wider use. The possible impact on heart attack mortality alone is enough to justify wider investment and exploratory use more broadly, even if the precise effects end up being smaller than that's cited in the article. This is a great example of technological change pushing the boundaries of what's possible in health care. (And frankly... even though I am not defending US health care prices, a high price for this new technology is exactly the kind of signal you want to send to entrepreneurial types, several of whom appear in the article. If ECMO can be taken out of the ICU (by some future version of the machine) that seems highly likely to generate huge benefits.) Sure, there are some moral issues to be worked out. Those issues would be much better worked out while a bunch of patients who would otherwise died are plugged into ECMO machines...
mynameisnoone 2y ago
ECMO is often a "Hail Mary" that rarely includes a favorable outcome. OTOH, perfusion is an under-staffed specialty offering a good career without as much academic investment as an MD. The downsides are the possibility of being on-call and sometimes having to be the one who pulls the plug.
- seriocomic 2y ago
  Having been the recipient of a double "Hail Mary" (extreme rare case - and luxury - of having two ECMO's used to sustain my life for 19-days after full organ failure post-pneumonia + severe allergic reaction to piperacillin/tazobactam) in 2014, and having a close colleague last month also receive ECMO care post-cardiac incident, I'm happy to say that we're both currently looking at 100% return-to-normal with no side-effects. I know there's a large spread of cases where the outcome is not as favourable as ours, but I'm not sure of the statistical curve justifying 'rarely'.
iancmceachern 2y ago
I've worked in this industry, designed several pumps. Check out Ventriflo, www.ventriflow.com There is so much opportunity for innovation in this space, it's like 10 or 15 years behind of what's possible
gagagaga7 2y ago
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062949 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.0... An interesting european study where patients with heart failure were randomized to ecmo or not ecmo, with no significant difference Studies like this are not often run in the us because there isnt a national health service which can facilitate this sort of trial, and no industry corporation has an incentive to run this either So when dealing with very expensive complex treatments which sometimes seem to “work” impressively, remember that it may be completely useless
- nickff 2y ago
  You’re mischaracterizing their findings: >” Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.” They still allowed for the use of ECMO if things got worse, they just didn’t start early. I don’t know how enough to know how this trial’s treatment compares to standard practice.
- ejstronge 2y ago
  I’d be careful interpreting studies when you aren’t a domain expert. Even if the results are accurate (no reason to think they’re not in this case), subtleties of experimental design that a domain expert would see may be invisible to an outsider. In this area, some groups are able to demonstrate a benefit and others are not. The thought is that hospital integration with field technicians is a big explanatory factor
- conradev 2y ago
  “Of the three published ECPR randomized, controlled trials, only one did not limit the intervention to people with shockable rhythms. That ambitious trial, in Prague, included patients whose hearts were in the same P.E.A. pattern as the St. Paul man’s. The study was stopped early when it appeared that ECPR wasn’t saving significantly more people than standard care was. These enigmatic cases that lack shockable rhythms are vexing: When the Prague data was reanalyzed without these patients, the findings were favorable for ECPR.” https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arrest-cpr.html https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arr...
nonameiguess 2y ago
I don't know why the story doesn't follow up, but it appears Shania Arms died last summer: https://www.eppsmemorialfuneralhome.com/obituaries/shania-arms-croft https://www.eppsmemorialfuneralhome.com/obituaries/shania-ar.... She apparently never got the transplant. Unfortunately, this was down a ways on web search compared to her GoFundMe, which is still up, so thanks to reading this after reading her self-told story of fighting so hard for 23 years while constantly being told she was about to die, I think I'm gonna disconnect from the Internet and go cry for a few hours.
keepamovin 2y ago
A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U. “It’s a trap,” Zitter said. Holy shit. I think we should keep people alive as long as possible, as long as they want to be kept alive. This is awesome. Hopefully in future the cost can be decreased and the safety increased. The pessimistic take is that meaningful improvements in the tech are impossible. I think that's not true. As an aside I think we need to really rethink circulatory system health -- seems a lot of death causes arise from circulatory system: ischemic heart attack, stroke, even kidney related diseases. If we can enhance the reliability / health of circulatory system it should have big effects.
DeathArrow 2y ago
https://archive.is/0GP4F https://archive.is/0GP4F
kwhitefoot 2y ago
> “This is a big problem already,” Prager told me. My boss was fond of saying "We don't have problems, we have challenges and opportunities!"
taxicabjesus 2y ago
ECMO is also a cause of death, when the patient's lung problems are worsened by hyperoxia [0]. [0] "Supplementary oxygen administration is widely used in emergency and intensive care medicine and can be life-saving in critical conditions, but too much can be harmful and affects a variety of pathophysiological processes. Reactive oxygen species are known problematic by-products of hyperoxia which have an important role in cell signaling pathways. There are a wide range of effects, but when the homeostatic balance is disturbed, reactive oxygen species tend to cause a cycle of tissue injury, with inflammation, cell damage, and cell death.[2]" - https://en.wikipedia.org/wiki/Hyperoxia https://en.wikipedia.org/wiki/Hyperoxia The Boeing whistleblower just got finished off with ECMO, according to the recent submission [1]. I think the progression of his illness must have been "poor oxygen saturation treated with O2" -> intubation -> ECMO -> death. [1] https://news.ycombinator.com/item?id=40230790 https://news.ycombinator.com/item?id=40230790

175 points by _xerces_ 2y ago

ECMO saved my granddaughter’s life 12 years ago at John Hopkins. She was born on Christmas Eve and weighed over 8lbs but turned “blue” within 30 mins of birth. She was immediately put on ventilator- dx with pediatric pulmonary hypertension. Later placed on ECMO when condition deteriorated and it saved her life. She spent months in hospital but is now a very active 12 y/o with no cognitive deficits. She is now on only one heart medication and recent heart catheter showed slight improvements. It’s my understanding she will always be on a heart medication. She came home from the hospital with a j-tube and was quite a struggle to get her to eat food or take a bottle as she never had a bottle or breast for months. It was amazing how articulate she was at a young age and how active as she had been in a induced comma for a long time.She will not be able to participate in competitive sports but can enjoy some sports for fun. She is on level at school. ECMO and the team including the surgeon who came in during the night to make the incision will never be forgotten. I still remember the team pushing the machine down the hall towards her room as a doctor carefully explained the ECMO. Not everyone is as fortunate as our “Warrior Princess” as she was in the right place at right time where the ECMO was readily available in Baltimore's John Hopkins.Margaret Evans

PaulHoule 2y ago

See https://archive.ph/0GP4F https://archive.ph/0GP4F

captainkrtek 2y ago

Another real world story on the usage of ECMO https://archive.ph/TZ90v https://archive.ph/TZ90v . A snowshoer got lost around Mt. Rainier, fell, and had to be rescued. He was hypothermic and went into cardiac arrest, with not a high probability to survive, saved by ECMO and had a full recovery.

idontwantthis 2y ago

This is definitely in the “nice problems to have” ethics pile.

OJFord 2y ago
What? In the sense that better to have that problem than just already dead because ECMO doesn't exist, you mean? Otherwise I can't think of any way it's at all nice, and that applies to any dilemma - you can always say 'oh well nice to have the option, better than only the bad lemma'!
- idontwantthis 2y ago
  I mean that countless people going forward will be saved by this. Some people will become ICU bound walking corpses. It’s an incredible technology that will have profound benefits for humanity.

jprete 2y ago

ECMO is a miracle, but can also lead to some of the saddest situations imaginable: "Without ECMO, she would die. But owing to the complexity of the machine and its attendant risks—catastrophic bleeding, stroke, infection, malfunction—she couldn’t leave [the ICU]. She was waiting, stuck in a kind of limbo between life and death."

MikeTheGreat 2y ago
To be fair that pretty much describes all patient visits to the ICU. You're not there because things are fine and you'll be going home soon, you're there because you're on death's door and the hospital folks want to keep you on this side of it.
- crote 2y ago
  The difference is that most other ICU patients are there with an (albeit slim) chance of recovery. Their body just needs time to heal, and the ICU provides the support necessary to do that. 75% of ICU patients are discharged from the hospital alive, and those who die often do so within the first few weeks. On the other hand, it seems some ECMO patients have zero chance of recovery. Their own organs have failed and aren't coming back, and a transplant doesn't seem to be an option. Sooner or later they will die in that room, most likely due to complications.
  - kelseydh 2y ago
    It really seems similar to dialysis, except more expensive. As technology develops and cheaper devices can be made we can democratize access to these lifesaving devices. It's in the interests of both you and I to democratize access to technologies like ECMO.
    - nradov 2y ago
      I'm not convinced that is in my interest. Personally if I'm in a condition where I need ECMO and don't have a good chance to recover with a high quality of life then I'd rather just check out. (My preference only, not a choice that I want to impose on other patients.) While this technology is amazing, at a societal level I am skeptical whether widespread use is the right way to expend our limited resources. In the USA we could save a lot more life years by diverting some funding away from advanced life support and towards fixing our appalling maternal mortality rate. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021...

lozenge 2y ago

Great article, did New Yorker abandon its rambling house style?

drxzcl 2y ago

Not to downplay the dilemmas we face today, it seems to me that the main problem is that the machine is too expensive, too complicated and too large to serve as a permanent heart/lung replacement. We have an excellent record of making machines smaller, cheaper and simpler to operate. This machine will be the pacemaker of the future.

sxg 2y ago
That's definitely not the main problem. Risk of intracranial hemorrhage/strokes and other complications make it problematic.
- saurik 2y ago
  But that isn't the problem from the article--the ethical issue of how to deal with a ton of people who are being kept alive on a "bridge to nowhere" when the machines might could be used in the interim to save many more people--as if you have an intracranial hemorrhage you are going to start down the road to actually dying. (And the article also talks about attempts to improve the bleeding problem anyway.)
  - toth 2y ago
    To me it sounded like part of the problem is that people on ECMO cannot leave the ICU because at any moment they might have a complication that requires immediate emergency care. So it's not enough to make them smaller and cheaper, they also have to be made much less prone to these complications. I am sure that will happen in time, but I am also sure we'll be able to grow people new lungs in time
    - FireBeyond 2y ago
      Critical care paramedic: that's very much the bigger issue. Some life flight helicopters are being fitted for ECMO and there is NOT much space in a helicopter, once you fit in two providers, a patient on a gurney and care equipment (most HEMS units are Bell 429s and EC/H-135s - MSP uses much larger AW-139s). https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.jpg https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.j... shows the working space on a -135. Note that access to most of the patient is heavily restricted - only chest and head, really. Still, to be clear, we are not really at the 'portable' stage either. There's about 65lb of equipment needed for an ECMO patient just for the ECMO itself, beyond other things like Lifepaks for monitoring.

FuriouslyAdrift 2y ago

ECMO is a last resort type treatment that has common life altering side effects.

sithadmin 2y ago
Yep. A good friend of mine who is a perfusionist (a relatively obscure midlevel med tech role focused on ECMO/CPB operations) has made it clear they would rather just be allowed to die than be subjected to either. The majority of cases they're involved with, but most especially the ECMO cases, per their account, are associated with what seems like unnecessary suffering pending death. Their opinion is that in most cases, it's probably not worth the extreme cost and effort, and that tracking 'survival' as the criteria for success is misguided given poor quality of life afterwards, and usually death related to long-term side effects/complications. They admit that their opinion may be clouded by the fact that they've self-selected into working in hospitals that are the most likely to take 'hopeless' cases, though.
- FireBeyond 2y ago
  I'm a paramedic, and in between seeing quality of life issues post resuscitation, ongoing care challenges and, unfortunately, the state of some skilled nursing and rehab facilities, myself, and I would say a "very very large percentage" of my peers are absolutely on the same page. Unless full recovery with no to minimal deficits is likely, not so much.
- Workaccount2 2y ago
  I have heard the sentiment before that ICU doctors would rather die than go through the ICU. Couple this with PTSD being a common side effect from ICU care and it starts to make a picture that maybe death is just the way to go.
  - jessriedel 2y ago
    No. This is not at all a representative opinion among ICU docs.

carterschonwald 2y ago

My niece was on Ecmo several years ago after a serious accident. She’s applying to university now. That’s what any non end of life treatment strives to achieve.

mezentius 2y ago

I fail to see how this is, as one specialist puts it, a “profound ethical dilemma," and not simply a temporary and embarrassing misalignment of resources. If you can prevent people from dying—and enable them to live meaningful, sentient lives despite being tethered to a device—then the solution is clear: scale up production while making the devices smaller and cheaper, and in the meantime seek out alternative long-term facilities for palliative care to avoid occupying hospital beds. The fact that the article frames the problem as "we have this fear of letting people die"—instead of a difficult but solvable problem of research, economy, logistics—seems to me emblematic of a certain dead-end, anti-growth mindset that pervades much of supposedly humanistic writing from the NYer. So what if this is "a bridge to nowhere?" So is life! And in the end, we are all, in our own ways, waiting for time to run out, tethered to something immovable.

feoren 2y ago
It absolutely boggles my mind that this is such a controversial viewpoint. We're talking about a machine that can keep people not just alive, but awake, talking, and riding an exercise bike, without working lungs or a heart. It's an insane, miraculous treatment, and extremely strong evidence that death is something we can conquer. And people come along and just downvote comments like yours, with no explanation at all, because it's so deeply engrained in their brains they they and everyone they love simply must die, and everyone who believes otherwise must be naive and stupid. Because death is this magical, spiritual, special problem unlike any other problem humanity has ever faced: the one thing we will never be able to solve? It absolutely is a dead-end, anti-growth mindset, and I don't understand it. Why is everyone so in love with death?
- jprival 2y ago
  It’s not a particularly fair accounting of the framing of the article, which also profiles people who are working precisely on making the technology more practical and portable and ends on a hopeful note. For the time being it’s a high maintenance way to keep people alive, though, so the ethical dilemmas of resource allocation are real.
DSMan195276 2y ago

samus 2y ago

It reminds me of the situation people used to face when they got Polio. Often, they got stuck in an iron lung for a while and quite a few also never ever recovered lung function, meaning they were stuck for life as well.

skerit 2y ago

"A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U." The only ethical problem I see is other people deciding what life is worth living.

margalabargala 2y ago
Fully agree. They have this case study later in the article: > Around a decade ago, a teenager who couldn’t be saved was admitted to a New England hospital. Like Shania Arms, he had cystic fibrosis. A previous lung transplant was failing, and his only hope was another transplant. He was put on ecmo while he waited. Two months later, doctors discovered that he had developed an incurable cancer. Now there was no way for him to leave the I.C.U. His lungs were beyond recovery, and the cancer made him ineligible for transplant. He was caught on a bridge to nowhere. > Some members of the medical team thought that ecmo should be stopped. Transplant was no longer possible, and ecmo machines were scarce. As long as the patient was on the machine, it couldn’t be used to save someone else. It’s also expensive; according to a 2023 study, the median hospitalization charge for covid patients on ecmo was around eight hundred and seventy thousand dollars, and prolonged cases can exceed several million. These resources might be needed to help other patients, and the boy couldn’t live in the I.C.U. indefinitely. > But others on the team disagreed. “He was texting with his friends,” Robert Truog, a pediatrician and bioethicist who was involved with and wrote about the case in The Lancet, said. He was spending time with family, and doing homework online. Because he could be awake on ecmo, he could still engage in activities that were meaningful. Situations like this represent a “profound ethical dilemma,” Raghu Seethala, an intensivist and ecmo specialist at Brigham and Women’s Hospital, told me. “The technology is ahead of the ethics,” another expert said. The technology isn't "ahead of the ethics" as the one quote indicates. This is a simple case of some people apparently advocating for killing a living, conscious, interacting-with-the-world teenager because he wouldn't just hurry up and die, and they want to use his resources for something else. I bet those same people would learn that over 80% of people aged 70-75 reside in a home they own, and immediately come up with a modest proposal for how to solve the housing crisis.
- 2y ago

feoren 2y ago

"The overarching problem here is that we have this fear of letting people die" This feels like a crazy thing to hear a physician say. Our acceptance of death as inevitable is a learned helplessness. Modern medicine is not even 100 years old by some accounts, and every new decade brings new "miraculous" treatments that naysayers called completely unrealistic before. There's no reason to believe that humanity will need to accept death as inevitable forever. Any theory of medicine that is based on accepting that people die is dooming itself to a primitive, barbaric existence. The ethical dilemma goes away if these machines become more portable and 100x cheaper, a transformation we've seen many times. From keeping a cat alive for 30 minutes in 1934 to humans in 1952 to days in 1971 to months/years in the 2010s-2020s to ... what, decades? Centuries? These people are having conversations and we're saying "well we should let them die because death is a part of life" -- no, it clearly doesn't have to be. Yes, there are cost concerns, triage concerns and quality of life concerns, but those are engineering problems that we know we could dramatically improve if we actually invested significantly in this technology. I do not accept that we should not be afraid of "letting people die" -- let's be fucking terrified of it and do everything we can to stop it, please. Because everything we've seen from medicine over the last 100 years indicates that we can. And to those who say that death must be a part of life or (insert societal problem with shaky justification here) will happen, I ask: what if the situation were reversed? What if everyone lived forever and we were facing overcrowding or whatever -- would your solution be to kill everyone nearing 100 years of age?

FireBeyond 2y ago
I don't think it's so much that we kill people. It's that we let them die. If we are truly, brutally honest with ourselves (and overcoming denial, social, religious, whatever conditioning here is a huge struggle), much of the time, the efforts we put in to keeping loved ones alive is really often more about us than it is about them. The elderly (and I'm generalizing, I realize) are far more accepting of death. It's easier to accept that when you feel you have lived a full and happy life. Contrarily, that full and happy life often involves having the presence of loved ones, who are NOT ready to accept that their life will be - or rather, will feel - less full and happy without that person. Even just simple denial is a huge thing. One of my first experiences in emergency medicine was an older gentleman, family patriarch. The rest of his extended family had been able to gather at the hospital while he was in and out of arrest. A provider and support person went to talk to the extended family, who was adamant about following his son, the 'number two patriarch', and his steadfast insistence, "He is a good strong Christian man, and he is going to be okay." (I say this not to mock Christians, to be clear, and also to be clear, he didn't mean in the "eternal life" sense, he and the family truly believed almost that divine intervention was going to take care of things). After some discussion on this, a decision was made to bring the son into the ER where we were working on his father. Seeing the hopelessness and futility, seeing his father the shadow of the man he knew, and all of that assorted detail was no doubt traumatic, but it also made it viscerally real to his son. No matter the concerted efforts of nearly 10 medical professionals, drugs, defibrillation, ventilation, we were not going to be able to keep his father alive, and there was not going to be any divine intervention. He watched this silently for a few moments, and then asked us to discontinue CPR and if his father's organs were suitable for donation. My heart broke for him. But this is a struggle we have not figured out, recently. We had it figured out, historically, by necessity, but we are complacent now. Leaving aside the separate issue of healthcare costs, you can still look at the ratios: In the US, on average we spend more on healthcare keeping someone alive for the last year of their life than we do on the previous decade. And we spend more on that decade than we do on the rest of their life. Some of which seems obvious, given youth, but nonetheless.

ok_dad 2y ago

I only wish the technology were better ten years ago when my father in law passed away. He was on one of these types of machines, but only after he had surgery and his heart and lungs were already failing for days and his body was weak. If they could have put him on the best and newest machine of today right away, then his body could have recovered a bit before they had to operate to fix his heart valve, which was faulty. I do have to say, at the end when we visited him before they turned the machine off, it was absolutely a horror scene with huge clear tubes with blood flowing through them and the machine was fully clear as well, I assume to let staff catch any clotting early. When they turned off the machine I almost couldn’t help but look at the machine and the blood filled tubing, knowing that my father in law was given a second chance by it even though it failed. I used to have nightmares about the scene I saw there, but now I think of how great it is that we can replace some of the most important organs with machines, even if it’s still limited to hospitals. Morally, we should advance this tech as fast as possible so maybe next people can use these in their homes, or as a backpack or something, then on to artificial organs inside the body. The people going on these machines today are pioneers and the things we learn today will help other down the line even better.

squigz 2y ago
> I used to have nightmares about the scene I saw there, but now I think of how great it is So many people are not able to get over the grief (or fear, or guilt, or a hundred other emotions) that are usually associated with this sort of equipment, so they're forever seen as a sort of necessary evil - perhaps similar to military technology: something we know we have to have and have to develop, but not something we want to use, or embrace. I wonder if more people looked at these technologies and their potential applications with a bit more optimism, how things might advance.
- ok_dad 2y ago
  The only reason I got over it was I worked at a medical device assembly factory and saw firsthand how amazing it was that hundreds of people worked together to design test and build life saving devices. I stopped caring about the blood and started rooting for miniaturization, like how computers my mother used were in rooms and today everything has a computer in it. It’s hard though because our natural and trained response is to be grossed out.

daedrdev 2y ago

There is some discussion about the long tail of patients who don't get better, but from the article, this machine seems like it has lead to some incredible outcomes. Better respiratory illness recovery for extreme cases, better ability to recover from some cardiac arrests, etc. Additionally, for most long term patients, the reason they exist on the machine is because a lack of organs for transplant. There is little hope for more organs now, but in the future modified pig organs seem like a possibility for people that could really transform the ability to save peoples lives. Like it is nice that we can have ethics questions about this machine, and hopefully it can give some terminal patients the chance to find their own peace.

xkbarkar 2y ago

I feel the article makes ECMO sounds like a viable common treatment for lung ailments. I have personal experience with ECMO. Disclaimer: I have no medical training. But I have had two loved ones in ECMO in my life. An adult age 48 and a premature infant that weighed a little over 600 grams at birth. The adult died after a very successful month in ECMO during routine change of tubes. Bled to death after a ruptured artery. The infant survived and is thriving today. ECMO is highly specialised, very expensive, incredibly intrusive and also requires large amounts of blood plasma. Blood plasma is not an abundant resource. Just the cost is almost twice that of a standard, expensive cancer treatment. "The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD". https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A%20The%20mean%20estimated%20cost,range%3A%2034%2C121%2D154%2C817 https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A...). Cancer treatment cost example https://www.asbestos.com/featured-stories/high-cost-of-cancer-treatment/#:~:text=At%20an%20average%20total%20of,for%20other%20common%20health%20conditions https://www.asbestos.com/featured-stories/high-cost-of-cance.... So adding to the dangers of using ECMO it is also very very costly. It doesn't make a lot of sense to promote ECMO as casually as this article does.

huitzitziltzin 2y ago
Hello - it's your friendly neighborhood health economist (and I have worked on a topic adjacent to ECMO machines). ECMO is unambiguously cost effective (even at US prices!) for the infant. (I'm not defending US prices - needless to say if anything is cost effective at US prices it's passed the hardest cost effectiveness test.) It's also cost effective (even at US prices) for the older patient. Honestly the cited figure of $213,000 is nothing compared to the value of a statistical life (for the infant) or a bit under half of one (for the adult) There should be more of these machines and they should be in wider use. The possible impact on heart attack mortality alone is enough to justify wider investment and exploratory use more broadly, even if the precise effects end up being smaller than that's cited in the article. This is a great example of technological change pushing the boundaries of what's possible in health care. (And frankly... even though I am not defending US health care prices, a high price for this new technology is exactly the kind of signal you want to send to entrepreneurial types, several of whom appear in the article. If ECMO can be taken out of the ICU (by some future version of the machine) that seems highly likely to generate huge benefits.) Sure, there are some moral issues to be worked out. Those issues would be much better worked out while a bunch of patients who would otherwise died are plugged into ECMO machines...

mynameisnoone 2y ago

ECMO is often a "Hail Mary" that rarely includes a favorable outcome. OTOH, perfusion is an under-staffed specialty offering a good career without as much academic investment as an MD. The downsides are the possibility of being on-call and sometimes having to be the one who pulls the plug.

seriocomic 2y ago
Having been the recipient of a double "Hail Mary" (extreme rare case - and luxury - of having two ECMO's used to sustain my life for 19-days after full organ failure post-pneumonia + severe allergic reaction to piperacillin/tazobactam) in 2014, and having a close colleague last month also receive ECMO care post-cardiac incident, I'm happy to say that we're both currently looking at 100% return-to-normal with no side-effects. I know there's a large spread of cases where the outcome is not as favourable as ours, but I'm not sure of the statistical curve justifying 'rarely'.

iancmceachern 2y ago

I've worked in this industry, designed several pumps. Check out Ventriflo, www.ventriflow.com There is so much opportunity for innovation in this space, it's like 10 or 15 years behind of what's possible

gagagaga7 2y ago

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062949 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.0... An interesting european study where patients with heart failure were randomized to ecmo or not ecmo, with no significant difference Studies like this are not often run in the us because there isnt a national health service which can facilitate this sort of trial, and no industry corporation has an incentive to run this either So when dealing with very expensive complex treatments which sometimes seem to “work” impressively, remember that it may be completely useless

nickff 2y ago
You’re mischaracterizing their findings: >” Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.” They still allowed for the use of ECMO if things got worse, they just didn’t start early. I don’t know how enough to know how this trial’s treatment compares to standard practice.
ejstronge 2y ago
I’d be careful interpreting studies when you aren’t a domain expert. Even if the results are accurate (no reason to think they’re not in this case), subtleties of experimental design that a domain expert would see may be invisible to an outsider. In this area, some groups are able to demonstrate a benefit and others are not. The thought is that hospital integration with field technicians is a big explanatory factor
conradev 2y ago
“Of the three published ECPR randomized, controlled trials, only one did not limit the intervention to people with shockable rhythms. That ambitious trial, in Prague, included patients whose hearts were in the same P.E.A. pattern as the St. Paul man’s. The study was stopped early when it appeared that ECPR wasn’t saving significantly more people than standard care was. These enigmatic cases that lack shockable rhythms are vexing: When the Prague data was reanalyzed without these patients, the findings were favorable for ECPR.” https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arrest-cpr.html https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arr...

nonameiguess 2y ago

I don't know why the story doesn't follow up, but it appears Shania Arms died last summer: https://www.eppsmemorialfuneralhome.com/obituaries/shania-arms-croft https://www.eppsmemorialfuneralhome.com/obituaries/shania-ar.... She apparently never got the transplant. Unfortunately, this was down a ways on web search compared to her GoFundMe, which is still up, so thanks to reading this after reading her self-told story of fighting so hard for 23 years while constantly being told she was about to die, I think I'm gonna disconnect from the Internet and go cry for a few hours.

keepamovin 2y ago

A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U. “It’s a trap,” Zitter said. Holy shit. I think we should keep people alive as long as possible, as long as they want to be kept alive. This is awesome. Hopefully in future the cost can be decreased and the safety increased. The pessimistic take is that meaningful improvements in the tech are impossible. I think that's not true. As an aside I think we need to really rethink circulatory system health -- seems a lot of death causes arise from circulatory system: ischemic heart attack, stroke, even kidney related diseases. If we can enhance the reliability / health of circulatory system it should have big effects.

DeathArrow 2y ago

https://archive.is/0GP4F https://archive.is/0GP4F

kwhitefoot 2y ago

> “This is a big problem already,” Prager told me. My boss was fond of saying "We don't have problems, we have challenges and opportunities!"

taxicabjesus 2y ago

ECMO is also a cause of death, when the patient's lung problems are worsened by hyperoxia [0]. [0] "Supplementary oxygen administration is widely used in emergency and intensive care medicine and can be life-saving in critical conditions, but too much can be harmful and affects a variety of pathophysiological processes. Reactive oxygen species are known problematic by-products of hyperoxia which have an important role in cell signaling pathways. There are a wide range of effects, but when the homeostatic balance is disturbed, reactive oxygen species tend to cause a cycle of tissue injury, with inflammation, cell damage, and cell death.[2]" - https://en.wikipedia.org/wiki/Hyperoxia https://en.wikipedia.org/wiki/Hyperoxia The Boeing whistleblower just got finished off with ECMO, according to the recent submission [1]. I think the progression of his illness must have been "poor oxygen saturation treated with O2" -> intubation -> ECMO -> death. [1] https://news.ycombinator.com/item?id=40230790 https://news.ycombinator.com/item?id=40230790