First of all… Happy Easter all 🙂
We all like to talk about adversity and how we overcome it. Rarely do we elaborate on clinical events and the sequence of clinical and/or operational failures that lead to unintended outcomes. The story below is a pretty straight forward account of mishaps and miscues that can snowball into the most negative event… The “M” in M&M that stands for Mortality.
Packed like Sardines
To put it mildly it was pretty crazy Sunday morning. I was doing an emergency heart at one hospital in town and got a call from our chief surgeon letting me know that there was a patient was crashing in the ICU and would need to be put on ECMO as soon as possible. I told him I would not be off bypass for at least three hours and luckily one of my coworkers made herself available to assist with the implantation of a V-A ECMO using the CardioHelp system.
So I got done with my case and heard the ECMO patient was stable, and that the decision had been made to transport this ECMO by ambulance to a well-known ECMO center south of the Ohio River. When I got to the hospital, everybody was kind of giddy, you know the place you get to after you successfully placed somebody on ECMO which of course saved or extended their lives, they are hemodynamically stable, and basically is a team celebration of success. Evaluating the situation, the first thing I did was to actually plug the Cardiohelp in, because in all the excitement the power cord had been re-situated multiple times, and somehow ended up on the floor.
The next thing I had to consider was the fact that we were going to not only transport this patient on ECMO, but this patient also had an IABP in place as well. Now these newer Datascope modules come with a transport option that allows you to disengage the primary control console, from the balloon pump infrastructure making for a much smaller footprint, but with one glaring omission. There is no AC power cord for the control console, therefore you have to rely on the intra-aortic balloon pump battery, which from my observation gives you about 45 minutes of operating time. Realizing that this trip is going to be about two hours one way, I decided I would scavenge extra batteries from three other balloon pump consoles here at this hospital.
We began the transport by getting the patient down from the ICU to the waiting ambulance. It was a larger ambulance in order to handle the significant amount of hardware we were towing along with us. Not only were we transporting the ECMO CardioHelp unit with a balloon console, but we had a vast array of IV drips that were coming along as well. The personnel involved in this transport were a perfusionist (myself), an ICU nurse, a paramedic, and two drivers. We were stuffed like sardines, and had to rearrange equipment based on the best spot for each footprint.
We have Plugs but no Extension Cords
I obviously was not going to run the CardioHelp on battery for the duration of this two hour trip, so I looked for a 120 AC plug which unfortunately wasn’t close enough to where the CardioHelp was situated for me to plug the CardioHelp into. After a lot of milling about looking for a solution, it took 30 minutes to find an extension cord at the hospital. I do believe at one point we must of had five people in the back that ambulance as well as the patient, and we were finally ready to go.
Not so fast! A completely unanticipated and unthinkable shocker. The driver could not get the ambulance to go into reverse and thus allow us to back up out of the ambulance dock. For some reason they had installed a safety feature for God knows why, that locks the transmission of these ambulances so they can’t accidentally go into reverse. But no one knew how to unlock the safety feature so they had to call the ambulance company itself in order to bring a maintenance person over to help get us into reverse. This is not going to take just 30 minutes, and clearly our patient was not a prime candidate for that sort of unanticipated delay. Since we were on hold, pretty much the entire support staff and personnel went back into the ER and I found myself alone with the patient and a paramedic. It was at this point that the patient (who is conscious by the way), got violently nauseated and started to throw up. This stunned the paramedic, who had no clue as to what to do, so I went to the patient’s head tilting it sideways so that he could throw up and not aspirate his own vomit. I asked paramedic for some suction, and after much fumbling around we finally got that to work. In my opinion, the primary directive for any transport is airway safety, which includes having suction available for events like this. That was not the case here, and as well dressed as our paramedic crew was in their paramilitary rescue gear, they were clearly overwhelmed and unprepared to deal with what I consider fairly basic lifesaving measures.
As a result of the vomiting episode, something must’ve happened with either the cannula position or the patient clamping down, because I lost all flow for the ECMO. Basically we went from 4 LPM to less than 1 LPM, and dialing up the RPMs was not the solution. I dropped flows to try to see if the venous return cannula might have somehow become obstructed by the vasculature sucking down on the cannula. That really didn’t do anything, so I asked for help and finally 15 minutes later, I had doctors and nurses all over the place. I explained the situation to the ER doctors, and the decision was made to go to the Cath Lab, get a CT, and make sure that the cannulas were positioned properly. This took two hours, and meanwhile the patient is still awake. I spoke with him many times throughout the entire transport , trying to reassure him that he was going to be fine. He was very conscious and alert and you could tell by his expression that he knew that when there were this many people hovering around him the way we were, that he was definitely in some trouble.
We hit some bumps on the road
What started out as an ECMO at 11 AM this morning, was now a two hour ambulance transport seven hours later.
We are finally on the road and the stretcher was equipped with 2 IV poles onto which we attached two arrays of IV pumps (4 IV pumps per array). It had been long time since I’ve been in the back of an ambulance, and the shock absorbers on this unit were horrible. Every single bump or dip in the road was incredibly hard, and IV pumps were swinging like windmills waiting for a tornado to hit. So I attached a couple of Rock Climbing Carabiners to the handle on the ambulance ceiling in order to attach the IV pump arrays more securely.
This helped stabilize the IVs at the head of the patient, but as we hit a huge pothole on the road, the IV pole at the base of the stretcher, gave in and collapsed so that the array of IV pumps, landed south of the patient’s knees. This reminded me of the turbulence you encounter on helicopter medivacs, but I was shocked at how weak the structure of the stretcher assembly clearly was. We raised the IV poles back up, but the structural integrity (or lack thereof) of anything attached to this ambulance was definitely a big question mark.
We arrived at the Mecca
When we finally got to the emergency room of the medical center that we are transporting this patient to, there was none there. No one was expecting us almost as if they didn’t know that we were coming. We had to explain who we were and why we were there- but none of us had a clue as to what unit this patient was going to.
There was no surgical or ICU team to meet us at the doorway, and we ended up requiring the services of an orderly to help us navigate an amazingly circuitous route on the way to the surgical ICU several floors above us. Based on the route we took, I could see that this was a hospital that had been added on to – many many different times, as old floors and walls merging into newer shinier floors and walls, finally bringing us to the ICU.
I introduced myself to the perfusionist and chief resident that were in the room and whose care I was transferring this patient to. The perfusionist was solid, a nice guy and he had a Centrimag console ready to cut into our ECMO lines. The resident looked at all of us as if we were peasants, and seemed irritated when I had the temerity to let him know that the femoral cannulation sites were pretty dicey and positional. I’m not put off very easily when it comes to things like this, just because I’m an unfamiliar face doesn’t diminish what I bring to the table in terms of clinical awareness. I’ve seen this sort of attitude before, when the staff at the destination site – deemed to be the experts on ECMO, look down on those of us that don’t do ECMO every single day. This sort of imperious condescension can nip you in the bud as was quickly obvious once the Centrimag was in line- and their team being totally oblivious to us failed to notice the fact that the Centrimag flows had dropped well below 1 LPM. So I casually pointed it out to them stating “you pretty much have no flow at the moment” and that definitely got their attention.
From casual to WTF?
The chief resident was pretty shocked and actually started looking at the leg and the ECMO cannulation site. The attending physician came in and wanted to know what was going on. I explained the situation to her and emphasized that the cannulas were very positional and that we had witnessed a similar incident earlier during the course of the transport. Meanwhile the resident is finally assessing the arterial cannulation site, moving the cannula back and forth, until a jet-stream of arterial blood hits his gloves and he immediately applied pressure and covered the site with his hand to try to control what was obviously a serious femoral bleed. It is clear to me that he had pulled the femoral cannula partially out of the artery and was trying to shove it back in blindly while at the same time trying to reassure his attending physician that things were under control – which they clearly weren’t.
The dinner bell rang and everyone woke up!
That ICU room became busy in a hurry, and since our team was clearly rendered to irrelevance, we decided it was time to leave and that our job was done here. We had put a lot of effort into this transport, and that gentlemen in the ICU bed had put his trust in us. You could look at this entire narrative and go point by point from one failure to another. Some were equipment failures, some were failures of clinical awareness, but most importantly there was a total process failure in terms of planning and practice. I could accept almost all of those failures at one time or another, and work my way through them. But what I cannot accept was the total arrogance and lack of empathy displayed in that ICU room in that much vaunted ECMO center. When things got real, yeah they went into another gear, sadly similar to the one that would not let the ambulance back up at the start of the transport.
The patient expired the next day…