USA TODAY International Edition
MIRACLE MACHINE
Lifesaving tech achieves amazing feats, but the odds and expense are often too much to beat
The latest miracle machine in modern medicine is saving people from the brink of death: adults whose lungs have been ravaged by the flu; a trucker trapped underwater in a crash; a man whose heart stopped working for an astonishing seven hours.
But for each adult saved by this machine – dubbed ECMO, for extracorporeal membrane oxygenation – another one hooked up to it dies. For them, the intervention is an expensive, labor-intensive and unsuccessful effort to cheat death.
ECMO, the most aggressive form of life support available, pumps blood out of the body, oxygenates it and returns it to the body, preserving life for days or months, even when the person’s heart or lungs don’t work.
It is creating “an entirely new paradigm,” said Dr. Kenneth Prager, director of clinical ethics at Columbia University Irving Medical Center. “You have a heart that’s not working, yet the patient is not dead.”
Most commonly used for newborns, ECMO use has climbed among adults. In the USA, procedures tripled from 2008 to 2014, to about 6,890, according to the federal Agency for Healthcare Research and Quality.
ECMO is designed to be a bridge to recovery, transplantation or an implanted heart device. When patients are too sick, ECMO can be a “bridge to nowhere,” leaving the patient in limbo, possibly even awake and alert, but with no chance of survival outside the intensive care unit.
ECMO’s expense is mostly due to labor: A person on ECMO must be monitored for complications, such as blood clots, infection and loss of blood to the limbs. A teaching hospital charged $4.2 million for a 60-day ECMO stay for a comatose 19-year-old man with acute respiratory distress syndrome who died, according to Dr. Merrit Quarum, CEO of WellRithms, a cost-containment company.
Three patient stories highlight the promise – and complexities – of this technology.
The seven-hour code
Dr. Jessica Zitter was in an ICU in Oakland, California, when a code blue went off. A 60-year-old patient had arrived with a heart attack. His heart went into ventricular fibrillation.
Despite all the hospital staff’s efforts, the man’s oxygen levels plummeted. Yet, Zitter recalled, he kept moving, giving her the feeling there was a life to be saved. The medical team moved to the next level: ECMO.
When an ECMO team arrived from the University of California-San Francisco, doctors stuck one huge tube into a femoral artery and one into a femoral vein. His pumped-out blood was black from deoxygenation. After it ran through the ECMO machine, it turned bright red. The patient was whisked back to UCSF to recuperate.
Zitter wasn’t optimistic. The patient had coded, and people and machines rammed his failing heart for seven hours before ECMO arrived. She was amazed to learn that he eventually got well.
It was “a crazy, crazy, crazy outlier case with a crazy, crazy, crazy outlier response,” she said. “When these things happen, people tend to look at them and assume that they will have the same odds. The reality is that they won’t.”
When patients receive ECMO for cardiopulmonary resuscitation, only 29% survive, according to the Extracorporeal Life Support Organization.
Saving ‘Santa’
Dr. Haider Warraich of Duke University Medical Center came across the more common outcome during his cardiology training.
Warraich was called to the waiting area of a lung transplant clinic, where a man in his 60s had collapsed from a heart attack. The man, who had white hair and a beard, played Santa at Christmas.
His heart, starved of oxygen, sped up into a malignant rhythm. CPR and electric shocks didn’t work. The team called in ECMO. Cardiologists did surgery on a blocked artery, but his heart never recovered. The man lingered for a month – on ECMO for his heart, a ventilator for his lungs and dialysis for his kidneys – before he died.
Warraich said ECMO was appropriate but doctors need more guidance.
An ‘unbearable’ choice
Deciding when to turn off ECMO can cause moral distress for medical staff, said Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School.
In one case Truog described in The Lancet, a 17-year-old came to the ICU at Boston Children’s Hospital. The teen, who had had one lung transplant for cystic fibrosis, was in end-stage respiratory failure. He needed another set of lungs and started on ECMO while he waited for them.
He was conscious, doing homework, texting friends and visiting with family. After two months of living in the ICU, he was diagnosed with untreatable cancer.
Clinicians were divided over what to do, Truog said. Some wanted to stop ECMO immediately. Others argued that the teen seemed to have a good quality of life on ECMO, and his family and friends “derived benefits from his continued survival,” Truog wrote. They argued that the family should have the right to continue this form of life support, just as with dialysis, ventilation or an artificial heart.
For the parents, Truog said, it was “unbearable” to choose a day or moment to turn off ECMO.
Clinicians devised an alternative: They decided not to replace the ECMO oxygenator, a part that needs to be changed when it develops blood clots. After about a week, the part failed, and the patient lost consciousness and died, Truog said.
“No matter how you do this, it’s going to be very emotionally upsetting to everyone,” Truog said.