EDECMO 108: On Scene Trial

In this groundbreaking EDECMO episode, Dr. Dinis Miranda joins Zack Shinar and John Marinaro to discuss the ON-SCENE trial, which demonstrated a dramatic improvement in cardiac arrest outcomes using prehospital ECPR. By equipping the Netherlands’ existing helicopter emergency medical services with ECMO capabilities, the team achieved 40% survival to hospital discharge compared with 20% in the conventional care group, with favorable neurological outcomes of 36% versus 13%. Remarkably, physicians with little or no prior ECMO experience were trained through intensive simulation to perform field cannulation, achieving ECMO flow in an average of just 45 minutes from arrest. The discussion explores the importance of rapid reperfusion, standardized protocols, remote ECMO expertise, and the potential advantages of bringing ECMO to the patient rather than transporting the patient to ECMO. The ONSCENE trial challenges traditional ECPR systems and offers a compelling vision for the future of resuscitation: build the system around the patient, not the patient around the system.

  ED ECMO Podcast — Episode Synopsis This episode of ED ECMO, hosted by Zack Shinar, explores the emotional, neurological, and psychiatric outcomes of ECPR and ECMO survivors — going beyond survival statistics to examine what it means for patients to truly live after ECMO. Segment 1: ECPR Training & the Delphi Analysis (with Shan Modi) Shan Modi, critical care physician and associate ECMO medical director at Allegheny General Hospital, discusses a multinational Delphi analysis surveying 50–55 ECPR experts across 20–25 countries to establish standardized learning objectives for ECPR cannulators. He and Zack then pivot to Shan’s commentary on an EXCEL registry study that prospectively examined quality of life in ECMO patients — revealing that 70% of ECMO patients either develop a new disability or die from comorbidities, underscoring the gap between binary survival and meaningful recovery. Segment 2: The Emotional Landscape of Survivors Zack and Shan discuss recurring emotional patterns in ECPR survivors: Fear of sleeping after arrest, worried it could happen again Survivor’s remorse — patients feeling disconnected from celebration because they “just went to sleep and woke up” Anxiety and depression months after discharge The ethical concern of advertising patients as “survivors” when they may prefer to simply return to normal life Segment 3: Post-ICU Care & Caregiver Burden Shan advocates for dedicated post-ICU clinics for ECMO patients (modeled on Dr. Brad Butcher’s work at Pittsburgh), offering multidisciplinary follow-up with PT, OT, social work, and psychiatry. He also shares early findings from his ongoing caregiver interview study (24 caregiver-patient dyads), revealing that caregivers face acute-phase overwhelm and subacute-phase stress, financial strain, and guilt over struggling to care for themselves while caring for their loved one. Segment 4: Neurological & Psychiatric Outcomes (with Dr. Sung Min Cho) Dr. Sung Min Cho, neurointensivist at Johns Hopkins and co-founder of the Whitman-Cho ECMO research lab, discusses: Acute Brain Injury (ABI) rates far exceeding ELSO registry reports — meta-analysis showing 17% in VA ECMO, 10% in VV, and 20–50% in ECPR Neuropsychiatric symptoms (insomnia, depression, anxiety) persisting in 30–40% of survivors at 6–12 months Lack of pulsatility in VA ECMO causing small vessel brain injury, analogous to known LVAD complications Rapid CO2 correction during ECMO initiation linked to hemorrhagic and ischemic stroke, confirmed in a swine model showing basal ganglia injury The Safe MRI ECMO Study — a multi-center trial using bedside low-field MRI (0.064 Tesla) on patients while on ECMO, finding a striking 44% ABI rate, far higher than any prior study, revealing subclinical injuries invisible on standard CT scans (cir-150-1955.pdf, Clinical Use of Bedside Portable Ultra-Low-Field Brain Magnetic Resonance Imaging in Patients on Extracorporeal Membrane Oxygenation: Results From the Multicenter SAFE MRI ECMO Study – PubMed) Segment 5: VV vs. VA Differences & Take-homes VV ECMO patients showed higher neurocognitive impairment, likely due to longer hospitalization, heavier sedation, and prolonged paralysis. Key recommendations for ECMO programs: Optimize initiation parameters (sweep gas, CO2 correction rate, pulsatility monitoring) Minimize sedation and benzodiazepine duration Establish long-term follow-up and support groups for survivors Recognize that neurocognitive sequelae are common — patients should know they are not alone The episode closes with both guests reflecting on how ECMO uniquely brings together diverse specialties — ED, surgery, critical care, engineering — unified around saving the sickest patients.

What happens when emergency medicine, cardiac surgery, critical care, ECMO, and human factors collide in the highest-stakes environment imaginable? Mark Ramzy takes us inside the CTICU to explore the art of resuscitation—and why knowing when to move fast, when to slow down, and how to work as a team may matter as much as the technology itself..   In this episode of ED ECMO, Zack Shinar sits down with Mark Ramzy, an emergency medicine–trained cardiothoracic intensivist, to explore what resuscitation looks like when the patient is already surrounded by ECMO, LVADs, invasive hemodynamic monitoring, recent sternotomy, and a highly specialized multidisciplinary team. Mark shares practical lessons from the CTICU, including how post-cardiac-surgery arrest algorithms differ from traditional ED resuscitation, when to shock rather than immediately perform chest compressions, how to recognize impending deterioration, and why knowing when to “speed up” and when to “slow down” can make all the difference. He discusses open-chest resuscitation, internal cardiac massage, VA ECMO as an exit strategy, and his experience with double sequential defibrillation. The conversation then moves beyond procedures into the human factors of high-stakes medicine. Mark describes working alongside cardiothoracic surgeons, interventional cardiologists, intensivists, nurses, respiratory therapists, and emergency physicians—and argues that successful ECPR depends less on territorial boundaries and more on recognizing what each member of the team brings to the table. Finally, Mark offers a cautionary perspective on the rapid expansion of ECMO and ECPR. As these technologies become increasingly accessible, he emphasizes the importance of quality control, mentorship, humility, and developing strong relationships across specialties. His overarching message is simple: medicine is a team sport, and the best resuscitation teams know not only what they can do, but when to listen, when to slow down, and when to let someone else lead.

EDECMO 105: Becoming an ECMO Coordinator? In this episode, hosts Zack Shinar and Jon Marinaro are joined by Jonathan Goldstone, ECMO Coordinator at Sharp Memorial Hospital, and Rachel Wallace, ECMO Coordinator at the University of Minnesota ECMO Program, to explore one of the least understood but most important roles in an ECMO program—the ECMO coordinator. The discussion begins with recent advances in their own programs, including dramatic reductions in ECPR cannulation times at Sharp through improved teamwork, standardized equipment, and streamlined workflows. This sets the stage for a broader conversation about how successful ECMO programs are built and sustained. Rachel provides a detailed overview of the ECMO coordinator’s responsibilities, including onboarding and training ECMO specialists, competency assessment, simulation education, quality assurance, ELSO registry management, physician education, equipment evaluation, and research support. Jonathan emphasizes that while coordinator responsibilities vary between institutions, the central mission is always the same: ensuring there are no weak links in the ECMO system that could compromise patient care. The panel clarifies the often-confusing distinctions between perfusionists, ECMO specialists, ECMO coordinators, and ECMO managers, highlighting that ECMO specialists may come from nursing, respiratory therapy, perfusion, or advanced practice backgrounds, while coordinators oversee education, quality, systems improvement, and program development. The conversation explores how hospitals should think about hiring an ECMO coordinator, arguing that programs should invest in leadership early—even before case volumes become large—to build the infrastructure necessary for safe and sustainable growth. The guests also discuss how coordinators influence equipment purchasing, mobile ECMO development, process optimization, billing, and multidisciplinary collaboration. A recurring theme throughout the episode is that ECMO is fundamentally a team sport. The guests stress that efficient ECPR depends less on individual expertise and more on standardized processes, constant communication, simulation, and shared mental models among physicians, nurses, respiratory therapists, perfusionists, and ECMO specialists. Finally, the discussion turns to professional development for new coordinators. The guests encourage listeners to leverage the ECMO community through conferences, podcasts, ELSO resources, WhatsApp discussion groups, and mentorship from experienced programs. They conclude by emphasizing that ECMO practice continues to evolve rapidly, requiring coordinators and physicians alike to remain curious, adaptable, collaborative, and committed to continuous improvement. Key takeaways: The ECMO coordinator is the operational leader who integrates education, quality improvement, data management, research, equipment, and systems engineering into a cohesive ECMO program. Successful ECMO programs depend on standardized processes, simulation, and multidisciplinary teamwork rather than individual heroics. Every hospital must develop an ECMO program tailored to its own personnel, patient population, and resources rather than simply copying another institution’s model. Continuous learning, collaboration, and engagement with the broader ECMO community are essential for building and sustaining high-performing ECMO programs.

Jon Marinaro interviews Dr. Eric Nadler along with Dr. Gary Schwartz our guest for the second episode in a row Key Takeaways Cancer is increasingly becoming a chronic, manageable disease. ECMO may be appropriate in carefully selected oncology patients. Close collaboration between oncologists and ECMO teams is essential. Modern cancer therapies can work rapidly enough that ECMO may meaningfully change outcomes. Awareness and education gaps exist on both sides: intensivists may underestimate modern oncology, oncologists may underestimate ECMO capabilities. Eric Nadler, M.D., MPP, is board certified in medical oncology. He serves as a medical director of US Oncology Health Outcomes. He remains active in US Oncology Network and Texas Oncology research committees in lung cancer, head and neck cancer, and sarcoma. Dr. Nadler’s passions are oncology research and oncology education.

Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak –   Episode 103 Key Points: ECMO in HIV/AIDS Patients 1. HIV Is No Longer a Strong Contraindication to ECMO Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO. With modern antiretroviral therapy (ART), outcomes have dramatically improved. Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy. Therefore, HIV alone should not exclude patients from ECMO candidacy. 2. Immune Reconstitution Makes Recovery Possible ART can rapidly suppress viral load and restore immune function. Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time. This means even severely immunocompromised patients may recover if given time and support. ECMO can act as a bridge to immune recovery. 3. ECMO Functions as a “Pause Button” ECMO stabilizes respiratory or cardiac failure while clinicians: Treat infections Start ART Manage complications This buys time for reversible disease processes to recover. 4. Major Cause of Respiratory Failure: Pneumocystis Pneumonia Common features in HIV patients requiring ECMO: Pneumocystis jirovecii pneumonia (PJP) Severe respiratory failure Cystic lung destruction Frequent bronchopleural fistulas and pneumothorax Ventilation can worsen these conditions. Thus ECMO is used to: Reduce ventilator pressure Prevent further lung damage Allow lung healing. 5. Ventilator Strategy: Minimize Positive Pressure Typical strategy: Rapid ECMO initiation if ventilation causes lung injury Attempt early extubation If needed: tracheostomy minimal ventilator settings Example “rest settings” described: Driving pressure ≈ 10 PEEP ≈ 10 (often reduced further) FiO₂ ≈ 50% Goal: avoid further lung trauma. 6. ECMO Candidate Selection Primary question: Is the disease reversible? If yes → ECMO should be considered. Factors supporting ECMO: Young patient Treatable infection Potential immune recovery Possible relative contraindications: Severe fungal infection Multiple uncontrolled opportunistic infections Extreme cachexia or severe systemic deterioration. 7. Early ART Should Be Started Modern approach: Start antiretroviral therapy during acute illness Do not delay until after ICU discharge Benefits: Rapid viral suppression Faster immune recovery Risk: Immune Reconstitution Inflammatory Syndrome (IRIS) Temporary worsening of infection due to immune rebound. 8. Circuit and Infection Complications Important ECMO considerations in HIV patients: Increased risk of circuit thrombosis Possible fungemia If fungemia occurs: circuit replacement possible re-cannulation These complications require careful monitoring. 9. Cannulation Strategy Example high-volume center approach: Bilateral femoral VV ECMO cannulation Fast Reliable flow Allows later neck access if needed Used especially during high-volume periods (e.g., COVID). 10. Outcomes and Indication Expansion ECMO indications are evolving: Older age Longer ventilator times HIV/AIDS Cancer patients All are examples of “indication creep” as experience grows. The key principle remains: ECMO should be used if there is a realistic chance of recovery. 11. Resource and Program Considerations Decision-making must consider: Resource availability Program experience Institutional risk tolerance High-volume ECMO centers can often accept higher-risk patients. 12. Broader Lesson Medical contraindications often change with new technology and therapies. Example given: HIV was once a contraindication for kidney transplantation Now it is accepted due to improved treatment. The same evolution may be happening with ECMO indications.

We need a major change in the way we think about the brains of ECPR patients.  We have been duped into thinking that they are the same as regular resuscitation patients, and the answer is that they are not.  On EDECMO 102, we learn about this idea from two wonderful people: Ingrid Magnet and Michael Poppe.  In addition to the inspirational ECPR program they have created in Vienna, they have published a paper showing just how different these two groups of patients are.  They show that ECPR patients improve their neurologic function tremendously over the six months following their event.  This really changes the way we need to think about these patients and how we discuss options with their families in the hospital.

How do we improve survival from cardiac arrest?  Does Head-Up CPR improve outcomes?  Paul Pepe, the premier expert in the field, gives us the data and reasons why head-up CPR can improve outcomes.  Dr. Pepe also discusses estrogen and it’s potential to improve resuscitation outcomes.  

On this 100th episode of EDECMO, Sydney’s very own Nat Kruit tells us how they organized a prehospital system.   She and her crew have a wonderful job organizing a cadre of new cannulators to now have a functional system that can provide the residents of Sydney the opportunity to benefit from ECPR.  Take a listen, she’s fantastic.

EDECMO – Episode 99 is a gem.  Charles Bruen tells us how he has become an ECPR cannulator within the prestigious Minnesota Mobile Resuscitation Consortium.  He shares pearls about cannulation as well as the next steps for Minnesota’s innovative approach to bringing ECPR to largest population that is possible. A couple of pearls from Dr. Bruen’s cannulation piece are holding pressure in the groin with the ultrasound probe, understanding that the inguinal fold does not represent the inguinal ligament, inserting the needle at a 45-degree angle, and insertion at the common femoral artery.