Hello, my name is Doctor Sarah Walker, and I'm honored to serve as the 2025 president of the El Paso County Medical Society.

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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

Life support can take on many forms.

Today we're going to talk specifically about ECMO or extracorporeal membrane oxygenation.

It acts like an artificial lung and sometimes like an artificial heart, giving the body some life saving time to recover.

This program is called the first ECMO program in the region and is underwritten by University Medical Center.

And I also want to say thank you to the El Paso County Medical Society for bringing this program to you for 29 years.

I'm Kathrin Berg, and this is the opacity physician.

Neither the El Paso County Medical Society, its members nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Thanks again for joining us.

Today We are going to be talking about the first ECMO program in the region.

We'll describe exactly what that means.

It's fascinating.

The team behind the UMC advanced life Support.

So with us this evening, we have two veterans and a new person, which I kind of think is fun because we're describing how we usually run the show.

And I say that we try to keep it lighthearted, keep the energy high.

But there's all kinds of questions I want to ask personally this evening.

But we have Doctor Leo Mercer with us, and he is UMC associate trauma medical director.

He's also the Texas Tech Health El Paso associate professor of surgery and the medical director of ECMO services.

That's a lot.

And we're going to come back to you in a minute and have you explain what all that means.

We also have Doctor Tiffany Lasky, and she is UMC pediatric and associate adult trauma medical director, also Texas Tech Health El Paso professor of surgery.

And we have Ivan Pete Garza, who is the UMC ECMO program director.

And I'm looking for all kinds of stories from you.

I know I came in heavy saying that because I think sometimes when we understand what it is that ECMO is doing, it helps people grasp on to what it is.

It's new, but very, very cool.

So on that note, Doctor Mercer, as our veteran on the panel and as a kind of the boss of the group, so to speak.

Describe what it is that you do.

I know that you were talking earlier that you're trying to split the roles of the associate professor of surgery, but also medical Director of ECMO services Where does that play into what we're talking about this evening?

You know, I think that the the roles that we play at Texas Tech and UMC are complementary, obviously.

And.

Well, with the subject of starting, an ECMO program came up, right after I first got back here and September 23rd, it became clear that we were the largest region in the country of largest metropolitan area in the country, serving the largest group of people and geographic area not to have an ECMO program that that was that was something that many of us felt compelled to, to create.

If you will.

And I'm going to repeat it, even though I did it in the opening statement, because the acronym ECMO and we're going to use it throughout the evening.

But ECMO again stands for extra corporal membrane oxygenation.

So before we keep going, explain to the audience what that means, so that when we do mention ECMO throughout the evening, they'll know.

--Patients that that have diseases involving the lungs in their lungs are failing adult respiratory distress syndrome, pulmonary embolism, eye injuries, pulmonary contusions.

And you simply cannot ask you need them or ventilate them using conventional ventilators without further damaging the lungs.

That's when ECMO begins to play a role there.

What that does is take blood.

In the case of B, V or B, no venous emo takes blood out of one out of the beta side and runs it through a pump and a filter oxygenates the blood and puts it back in.

And so what we can do is we can allow the lung to rest by no longer exposing it to high pressures on the ventilator.

And, and yields really very good results in terms of dealing with patients with those conditions.

Okay.

Nicely explained.

I like that.

Doctor Lasky, let's talk about your role.

So technically your role is UMC pediatric and associate adult trauma medical director.

Also professor of surgery.

So in this night's discussion, because, again, you guys do so many things.

But bringing it back to ECMO, how would you describe your role with ECMO what we're going to talk about tonight.

Well, I'm one of the ECMO physicians.

I am a surgical intensivist.

We help with Cannulation and we also manage, the patients that are on the circuit that are critically ill on the surgery service.

And, you know, we can talk about this more later with Doctor Mercer and Ivan can help explain as well that, the uniqueness of our model, because our surgeons know a lot more than a lot of other cannulators or--Describe what a cannulator is?

--they're the size of a garden hose, okay?

They go into people's arteries and veins.

Okay.

The size of a garden hose And even someone who's done surgery for 20 years, it can be a little scary.

But this is something that we need to do to accomplish the flows that we need to, to do what Doctor Mercer is describing.

So, we, we definitely, we definitely have had some scary moments, but learning moments to.

And that's something too, And I'll bring this up quickly.

We were talking prior to the program, that ECMO has been part of El Paso since January 31st, 2025.

So about a year and a half in not quite a year and a half in.

And I'm looking forward again to stories because as with everything you learn as you go.

So that's going to be kind of interesting.

We put the cannulas in, but we also manage the patient.

And I think and we know a lot about the pumps as surgeons.

And I think that's different than a lot of places.

Okay.

And I like to I love bragging about El Paso.

So we get to that point.

Let's talk about other programs around the country and why we are different that way.

Ivan, I would love to talk with you about being the program director.

First of all, how did you get that position?

Right?

Because again, this is relatively new in El Paso.

Are you from El Paso?

Describe a little bit about yourself so the audience can kind of go, oh that's Ivan.

So I'm actually from near San Antonio, Texas.

And most of my ECMO experience comes from working in that region, but working in that region, I've also been part of teams that have had to come to El Paso and pick patients up and take them back to San Antonio and care for them there.

So I knew there was, definite disparity.

And, you know, having, patients displaced from families and, and such.

And when I had the opportunity to apply for a job, that, you know, where we can, develop a program in a place that really needed a program.

It was very hard for me not to apply.

I like the way you said that.

It was like, do you like El Paso so far?

I love El Paso.

--okay?

We usually talk about people who are relatively new.

If you're in El Paso and you ask people where you went to high school, but if you're a transplant, we have to ask you what your favorite Mexican food restaurant is.

We'll ask you toward the end of the program.

Think of a good one, though.

Doctor Mercer.

So as I was talking about earlier this first year, first year and a half, with UMC.

So and I want to talk about this news, you made a point of an earlier.

It's UMC in partnership with Texas Tech Health El Paso.

So talk about that partnership and how that works with the ECMO system.

It's a working relationship that that that reflects in large part the integration of Texas Tech health El Paso and UMC.

We've been partners for a long time.

I initially came to El Paso to finish my last two years in medical school, 9078, and spent 20 years here thereafter, working and training and being a trauma fellow and enjoying the trauma surgery service until I left in 97 and moved to New Zealand.

So while familiar with the organization, the organization for women, Good or bad remembrance makes But so that relationship was something that we built upon, Doctor Lasky is a surgical intensivist as am I we have two pulmonary critical care physicians.

So that's what we started The program with.

We've now expanded 2 to 1 more surgical intensivist who cannulates and manages ECMO patients there.

One more thing.

Pulmonary critical care specialist.

So we have a total of six.

Those people are all on faculty at Texas Tech Health El Paso, working with UMC, helping in the training of the staff, the ECMO specialists working with Ivan In terms of laying out the the acquisitions, if you will, the capital for starting, for there and setting up the training, the education, the conferences, all the policies and procedures, all of the things that we have to do in order to stand up a program that, that is both lifesaving and associated with high risk.

And that's just kind of the nature of ECMO, people don't hit ECMO on a winning streak you don't wander into the ICU and go, oh, you.

I'm feeling really pretty good.

I think I'll go on an ECMO circuit.

So all of that is within within the framework of policies, procedures and education, maintaining competency and all those sorts of things that it takes to stand up a program like that.

So, Doctor Lasky, I think that was a great transition.

When you were talking about ECMO circuit, I would love if you could, and maybe we can show a photograph tooo or an image of this or two, but what can you describe what the circuit looks like and what it is doing?

You talked about garden hose earlier, and I just love the fact that you are a descriptive person and I it I appreciate that very much of what exactly is happening during the circuit ECMO, so to speak.

So like Doctor Mercer said, these patients are incredibly critical on the brink of death, and they need oxygen desperately.

So, the cannulas, we deal with BV and VA renal venous to veins or vena arterial, a vein and artery.

Okay.

And the simplest way to describe it is blood comes out through a big hose and it goes through and oxygenatr or so and then it goes back into the body.

And you can literally see a difference from the blood that comes out.

Yeah.

And then the blood that comes from the oxygenated and goes in the body is bright red.

It's incredible.

And I knew it was I knew it was a cool thing.

But until we started doing it, I didn't really grasp the power of it.

So when a patient is on an ECMO circuit, and you said this is, like, dire, is there a, an average number of hours, days that this occurs?

And is this hurt?

Her smiles teaching me like, oh, is that a hard question to ask?

Well, no, harder to answer.

We have people on for 3 to 5 days, right?

That's our average.

But, there it, it could be less.

It could be more.

And there are times when it can be a lot.

Okay.

Okay.

So here's the, prequel to that question.

When they're in dire straits, what is it that in between the two of you let me know.

When is it that.

Okay, we need to put this person on the ECMO circuit.

And if we didn't have the ECMO circuit, would they simply not make it?

And I'm going to start with you and Doctor Mercer If you want to throw in some some thoughts on that as well.

Yeah.

We've had many patients.

Who were on the brink of death before they went on to the circuit and, and it and we weren't really sure at the time.

If they were going to make it in what conditions get them to that point?

It could be heart attacks.

Would it be trauma and all of the above.

So, massive intoxication from different medications or, we even had a patient with carbon monoxide poisoning that we put on circuit.

But there are also times, when the lungs are failing like an doctor Mercer mentioned earlier.

And that could be from aspiration or some other event.

And we talked Doctor Mercer, we there's a there's a really very good picture.

And the first cannulation in the background, you can see the ventilator and you can see the monitor.

And the patient went on a circuit, our very first, with the heart rate of around 4050 with an O2 saturation of about 65 to 70.

And you can see the pressure on the ventilator, the pressure required to ventlate that patient going into the 4045 range, just high pressure in order to keep the patient as oxygenated as we could, which really wasn't very high.

Normal oxygenation will tolerate for a period to 90% oxygenated blood.

This patient was it was 70.

Well we we actually calculated.

So going back to that that question is always nice to picture.

What is it that gotten that patient there.

And that's what is or some ideas of of what that did.

It was a patient who asked for it.

Okay.

And was in the ICU and pulled his own new nasogastric tube out that was emptying stomach and and subsequently aspirated and caused a massive aspiration.

And when that happened, it's the acid in the stomach secretions.

Wreaked havoc on the pulmonary system.

So this was a patient that had we not cannulated why did would not have survived or we see that multiple times.

Likewise what is CPR which is ECMO CPR or patient's heart stop.

And they're fortunate enough to have effective CPR for a period of time.

Oh and then we can go in rather quickly.

Cannulate for in this case VA.

It will be arterial ECMO to support the heart.

So describe how an ECMO CPR would occur.

Like what if I if I am watching a movie and you're describing this to me, what would that description look like?

The first patient that we put on CPR circuit a VA circuit.

Ivan remembers that while it was a patient that was being transferred to us, having a toxic ingestion in this case, he'd been drinking, gasoline, and we accepted him and transferred from one of the other hospitals in town.

and five minutes out from our emergency department.

The patient arrested.

So paramedics, the EMTs, pre-hospital care from El Paso fire started.

What is the final effective CPR patient came to the E.R.. We put a device on called a Lucas device, which delivers predictable, sustainable CPR in those patients who through a mechanical means and cannula to the patient and put them on.

VA ECMO Okay.

That's that.

Then our average time to get somebody cannulated in that circuit in that circumstance is about 6 to 8 minutes, 6 to 8 minutes.

That's it.

Okay.

So Ivan this was a nice way of bringing you into the picture too.

So this evening let's talk about this patient this evening.

This is something is this your first encounter with ECMO or is it just something that you may remember because of the unique circumstance and drinking gasoline?

Goodness gracious.

Describe what that was like on your end.

So definitely not my first encounter with ECMO but, it was a very unique case, and a very young patient who.

So it it was definitely something that will stick with me.

How young help me out.

I would say mid 20s.

Okay.

Okay.

Yeah, but when, when we put them on, just like Doctor Mercer said he was on, the Lucas device, which is, you know, a mechanical means of CPR.

And, when you get a patient on VA ECMO you're able to essentially take over the work of the heart, and allow that heart to rest, you know, recover it, maybe get go for some type of definitive treatment.

And once, we had him on the VA circuit, we had, sustainable blood pressure.

His oxygen was a little bit better, and we were able to get him to the ICU and continue, you know, intensive care.

And I'm still trying to picture this, and maybe I'm.

I'm a knucklehead.

I'm not able to picture it.

So you're talking about it's CPR, mechanical CPR, but in the circuit itself.

And I know we'll have an image when this airs.

But describe to me what that looks like externally going into the bottom.

And doctor, lastly, if you want to help out with that, describe the the the way that would work physiologically in the body.

Again, you're trying to help the lungs help the heart at the same time.

How is that working in tandem?

So you're drawing out the blood.

Bring it in into the oxygenated right, filling it full of oxygen and putting it back in.

And here's the actual physical pumping of the heart at that time.

Or is it the blood system that's causing the heart to pump because there's pressure going back into the heart, putting it back into the artery?

If the heart fails, you actually don't have to push in on the heart to do CPR anymore.

That's how well it supports perfusion to the organs.

Think for a moment about heart.

What about oh what's describe wrongly is open heart surgery.

But but those patients are on a perfusion device and the heart is being bypassed okay.

So the heart's still er stands still so that they can do surgery on the heart.

And then they restarted at the end of it.

And after the cannulate, those are, those are runs that probably last 3 to 4 hours.

And then the patient surgery is done.

They can be decannulated You're waited in the O.R.

and heart start stop or other starts and life goes on.

In this circumstance the heart isn't stand still.

There were actually pushing blood into the arterial system through our ECMO surgeon, and this can be happening as surgery is going on.

Well, in the case of perfusion for for and Ivan is also a perfusion.

So he can expand on that.

So but the idea behind perfusion and heart surgery is that you can operate on a quiet heart a heart that's not moving That can do all the anastomosis or the connections that one one has to undergo because the blood is oxygenating the body, the air externally.

Interesting.

That's essentially what we're doing.

But we we typically can run on for a lot longer.

So a patient on the VA circuit until the heart recovers.

Could mean being on a circuit for three, five, seven, ten days until that heart has recovered.

But that's that is kind of the analogy.

And a lot of ECMO came about from that, that that perfusion world to an open heart surgery.

And then came out of that was perhaps more, more effective pumps, pumps that can be used that didn't, didn't disrupt your blood cells and things of that nature became a little more a traumatic circuits that were specifically designed for, for long term.

EMO - VV or VA so okay.

But yeah, imagine that you stopped the heart and surgery.

Well, the heart stopped because he had gasoline and had all the metabolic consequences from drinking gasoline.

And its heart stopped, at the time that we got on him, his heart had stopped.

And Miller, when we were getting native heart function, was to push on it.

Then what we do with the ECMO was take over that function where we pull blood out of the remaining side, run it through a pump, through a oxygenator, and inject it back into the arterial side.

So then it effectively diminished from the role of the heart.

So here's a question.

When you said a little bit earlier that you said this could be several days, seven, eight, nine days.

And in that time frame the heart is recovering.

So it's doing the work of the heart.

And this is just where science and medicine is fantastic.

So just the body is starting to not heal the heart.

But for the lack of a better word, you said recover.

How is that?

If you can describe what that means?

Because again, you're letting the heart rest for these many days because an exterior device is doing the blood pumping for you again, lungs and that's also pumping is a bit of a misnomer when we use pulsatile flow in ECMO, at least in this country, it's available in Europe Its the same pump that we use, but it's not approved in the US.

So what we're supplying arterial oxygenated blood to the rest of the body.

In non pulsatile flow.

But essentially what we're doing is allowing the heart to recover.

or we're correcting the metabolic abnormalities that caused the heart to stop in the first place.

Okay.

And in the case of monoxide poisoning, which was once one of our cases it was the patient came in with a fairly very low rejection fraction.

Percentage of blood that was coming out of his heart was almost immeasurable.

5 to 10% ejection fraction.

And what what what Doctor Lasky and Ivan did was put him on a VA circuit support them until they could off gas the monoxide.

And what that means just after a while it just leaves the system because we're able to pump through the system.

Okay.

There's a lot that goes into monoxide toxicity.

It's not just hemoglobin loading and unloading.

It's some other things that happen cellular level.

But if you can keep patients alive long enough for the the body to effectively uncouple the monoxide from, from the cytochrome, getting it off the hemoglobin, it's really not that big of an issue but supporting that patient.

So you could have recovery of the heart, long enough for them to, to deal with the consequences of monoxide toxicity.

That's what we're looking for.

This is not a definitive treatment.

It's not like you leave the hospital with a couple of cannulas dangling from you from your left groin.

But.

But it's designed to, to to support cardiac function and lung function.

So the thought that the body can heal or we can implement different interventions, different therapies, that that resolve what caused the heart function to fail.

Okay.

That's starting to make a lot more sense to me.

Ivan I want to go back to you, because we were talking about, a profusion list.

Profusionist which is hard for me to say.

So that is something you do.

That's something you are describe with that is.

And I think that for the most part, we kind of have the gist.

But before ECMO came along let's talk about that.

So so a perfusionist is a health care provider that manages the, heart lung bypass machine.

In the OR Okay, they do other things on top of that.

So I'm, I'm not a perfusionist.

I worked as a perfusion assistant.

But, and it's very close to what an ECMO specialist or ECMO primer is as well.

Because the two fields are so close together, you know, you're able to, know the ins and outs of the machinery that you're, taking care of the patient that the patients on.

And, and a lot of times, perfusion groups will use ECMO specialist as perfusion assistance to help them get their machines ready and actually help them run cases, under that direction, you know, while, they're doing open heart surgery.

But, as far as ECMO is concerned and the machinery.

So, we think of ECMO and we think of a machine that has a pump and an oxygenator or some big tubing, some big cannulas, but, I would, say that ECMO's a little bit more than just a machine.

It's also the team that's involved with it.

Right?

You have, nurses and respiratory therapists that are trained as AML specialists.

They have to have, critical care experience to even, be eligible to become an actual specialist.

And then you have physicians as well that go through the same training.

So that in essence, everybody on the team is interchangeable.

As an ECMO specialist, and you have, you know, your, your leadership group as well, that's able to support the program.

So, so when I think ECMO, I think more than, like I said, more than a machine, but the whole system.

Okay.

And I'm going to repeat this again just for people who may just be churning in.

I know we're saying ECMO a lot.

But what ECMO means is extracorporeal membrane oxygenation.

Just so a kind of takes in a little bit more.

And you were talking about training.

And so I'd imagine that the amount of training, that this requires, it's you.

It's a team And I love what you talk.

There's a lot of cross training happening.

How how did you go through your training?

What is it?

Training.

Provide everybody.

So.

So the first portion of training is a didactic portion where we teach, some physiology, and some advanced critical care science to the, people that want to become ECMO specialists.

And then we also have the technical aspect of teaching the machine itself, how to deal with, scenarios that might include, you know, troubleshooting something that's regular, like a small clot in the system, to something that's a little bit, that's something that can can be even bigger, like, a clot that stops the system or, a break in the system where the blood starts to come out, you know, and they have to recognize these and trend these patterns so that they can catch these events before they become a big issue.

Because when the patients on ECMO essentially, you are their life support.

And if you allow the system to stop, you know, they they may not make it.

And, can so when we're talking about, again about the cross training, so when you started this and I'm trying to think of what the unit looks like now, and for example, we had a cardiology program a couple of months ago and what the pacemaker looked like then compared to what it looks like now.

And I'm just trying to think of what the ECMO looks like now, what did it look like a little bit before, and how do you see it being in the future?

And I know that's a lot to kind of put together.

But again, I'm trying to think of when did ECMO start around the world?

I know you said that there's a lot of approval that needs to be done.

The United States has a lot of stuff that's happening in Europe.

And Doctor Mercer, feel free to kind of to go in on this.

But what is the ECMO machine look like now compared to when it first arrived?

Right.

When it, when it and so when ECMO first was implemented, the machine itself was probably about as big as, a spin, a piano.

Oh, wow.

So, so pretty large machine.

Maybe around 20 years ago, you started to see, more machines that were, based off the perfusion based machine.

And it might be, the size of, a portable keyboard, you know, so they could sit in for, like, a lap keyboard.

And then today you're going to see machines that might be, as big as a stack of books, you know?

So we got maybe a little taller, but.

Yeah, that's on the camera.

I'm not sure if those are on the camera, but there you go.

Okay.

About this.

Okay.

Right.

All right.

So much more portable.

Okay.

And with that, of course, there's more room, in the patient's room, you know, that that you're, you have available to you.

But also, with portability comes the ability to move patients.

So these patients that were on the brink of death, some of them are on ECMO, and you're able to wake them up and walk with them.

And while you're on the machine.

Right, okay.

Okay.

So talk about we talked about earlier.

So there's, there's Europe.

There's some things that they're allowed to do in Europe that we don't do yet.

And I like using the word yet.

But go ahead.

You know, and, you know, Ivan's give a really good representation of kind of where we came from in, in this world, corporeal life support or ecosystems described, from large machines that will occupy something that look like this bureau over here.

And different types of oxygenators bubble oxygenators where you actually kind of just bubble the open the oxygen into the blood and to recirculate it that way to changes in technology and membranes that allow us to to oxygenate the blood.

And a canister that is about this big around and maybe that long two carries two oxygenators Now that the newer oxygen is, oh, flat.

About that thick.

Oh, that that did the same thing.

So and having pumps that are centrifugal pumps, some of which are offset and spin at a high rate of speed, but, but are so precise that that makes it pump blood through the oxygen and ultimately into the patient, do very little damage or less damage to, to the patient's blood components like red cells and platelets and things that, the larger perfusion type devices were capable of doing that.

That allowed us to keep people on a circuit, whether VA or VV circuit for longer.

I mean, nobody kept I think for the most part, nobody aspires to keep a patient on a heart lung machine for six, eight, ten, 12 hours.

That's where Agonal comes out a week or so, actively doing the same thing, for a longer period of time, using our hardware that's evolved over time.

Now we're starting to look at devices that I would describe as whole neck bone.

We're we're really I'm a patient who just needs oxygen.

Maybe a COPD year.

That's retaining CO2.

And our oxygen areas are very good about loading oxygen and unloading CO2.

We're not quite there yet.

So that's a that's a great case.

So with someone with COPD because that's not going to go away.

Is this something that they come in and do every like you said it's a life support system.

Is it something that they repeat every couple of weeks in a couple of months?

I think it's something that that that as we get smaller and smaller cannulas that we can place in smaller, smaller vessels, on the VV side.

Yeah.

I've seen devices in development now that that don't require a big pump component, don't require a big oxygenated component because your oxygenation become far more efficient the pumps and become far more effective with smaller size.

So yeah, there are things on the horizon, but this has been an evolution over the years.

If you look at the first ECMO patient, put on on ECMO circuit at University of Michigan, it filled a room so give me an approximate year when that was --1970s.

A lot of them seem to again.

Okay.

So I mean, literally fill the whole room in addition to all the, what we would describe now as archaic sort of support systems in an ICU in 1972, big ventilators, big.

I mean, infusion pumps were probably not, not largely nonexistent then.

So you had you had bags and bottles of fluid are hanging around, and you had this big, or this big perfusion oxygenator in the background trying to keep the patient alive.

So I don't know if you all know this, but we have an iron lung upstairs in this building.

So the building where we filmed this program is the El Paso County Medical Societies home.

It's a building.

It's a Trost building, but we have a medical museum so to speak.

It probably came from hospital, I believe it did.

And I probably took care of the patient on it Yeah.

And I think we have a photo of that.

That'd be great to to insert here too.

So let me go back to Ivan for a moment.

So you've been here.

Have you been here since January of last year?

I've been here since prior to that.

April of, 24.

Okay, okay.

And in that time, is it all in prep for the ECMO system that is now in El Paso and in places?

Okay, so here's another question.

And it's a money question.

It's an awful question.

But we have one now.

Do we see because it is portable.

People coming in from other areas of the country, Texas, I don't know where the closest ECMO machine is other than El Paso, and I'm just throwing that out to anybody who might know is that Albuquerque?

Albuquerque?

Well, actually, that's not counting, you know, not not counting Chihuahua City.

I don't use my my land, miles.

That's the closest ECMO capable service, but ours is Albuquerque.

And then following that, Tucson.

But we where we cover, 140,000mi Okay, that was kind of West Texas and eastern and New Mexico.

So 1.4 million 1.5 million people in that area.

So yes, people come in from we've we've taken patients from as far east of us as, as, as Midland, Odessa, and as far west as a, as just south of Albuquerque.

But again, that mirrors kind of our service area for the travel program.

We've taken patients from local El Paso community hospitals.

We've taken patients from from hospitals and Las Cruces, New Mexico.

And that that has been.

Well, well, Mr.

Centro and Jacob, tasked us with setting up an ECMO program that was not just for UMC.

It was for the region, because we're we're in this very large geographic island if you will, and for West Texas and or were we not to do that, the fact that it hadn't been done, it simply would not have happened without without that that leadership and that guidance and that commitment to to creating a village, as Ivan described, because it truly does take a village to set up an ECMO program.

So let's let's go back to yes, it's the pinnacle of, of what?

Something like a level one two trauma center or stroke center or any kind of hospital level in there.

So let's talk about that.

And that takes a lot of infrastructure and it's incredibly resource intensive.

And so that costly.

Yeah.

That UMC is the only level one trauma center in the region as well.

And poor Ivan, I keep trying to, to to get questions to you.

So with this now and I would love for you to talk about a time where a patient.

So again, the idea was about 12 patients.

We're going to be serving the first year, and there are over 30 patients served in that first year.

So that's a lot.

And that just see what the need is is fantastic.

So think about when you have had a patient come in from somewhere else.

Where was that from.

And again it's stories right.

Like what is it that caused them to need the machine.

We brought them here, El Paso rather than the UMC again in partnership with Texas Tech Health.

Talk about one of those or 2 or 3 of those case studies that might come to mind.

Well, so even before we started the program, you know, they, they approximated that you probably get the program running within a year of me starting, the development, phase, maybe about three months into it, we had a patient that needed ECMO Of course, we didn't have an up and running program yet.

But we were able to identify this patient and send them out to San Antonio.

And when he got better, they set them back, and he was able to continue his care here.

And it just kind of lit a fire.

I didn't think I can sit around for, a full year and not have a running program.

So, you know, maybe another three months after that, we put our first patient on, in fact, we weren't we weren't, slated to start the program till the day after we were.

We were going to start the program on February the 1st, and it just so happened that a patient, needed the service.

And I got the call from Doctor Mercer saying, hey, there's someone that looks like they might be a great candidate.

But he may not make it till tomorrow.

Well, we, we did what I described as, like, soft opening.

Okay.

Well, yeah, I mean, it's it's more about it.

Yeah.

And, you know, Ivan is you know, we've Ivan stood this program up in eight and a half months So Ivan got here March or April--overachiever And and and January 31st for the first patient.

There and I think the that Ivan recognized to almost work you know, it's certainly the, the Army medical Center.

Oh.

Provided a service for which we're grateful, unfortunately, because most of our patients are civilian.

So, they had to request for ECMO Made two ECMO program was associated with a request to to the Pentagon to take secure permission and to secure an aircraft that they could fly their crew out.

Put patient cannula to patient here.

Patient back on the plane, send them back to San Antonio where they would be taken care of in their in their Dempsey hospital and run by their ECMO program.

So roughly 5 to 6 patients a year.

Would be able to be transferred to, to Dempsey.

And and what what what we found once we stood the program up, was that there was a pool of patients that had now that we had ECMO we could put on a circuit earlier, that we didn't expose them to what I would describe as really aggressive ventilator, conventional ventilator management, which, because of the pressures involved, would, would damage to long.

Oh.

So what we found was that, in the course of beginning our ECMO program, we realized that, our threshold might have been high to transfer a patient to See, it didn't need to be nearly that high if we could provide that service in our hospital in El Paso.

And that's what we've done.

Our program was was reviewed by one of one of the well known ECMO specialists in the country, attending use to run Albuquerque's program.

And, description on a podcast was and we are aggressive, but appropriately so.

Patients patients do better if we recognize the need, and do and do things that can be done, to those patients as intervention, it's like proning the patient like, like doing other things that we can do that don't require them to be on alert because they haven't reached that point.

I mean, we have we have guidance, we have checklists, we have things that we look for, that tell us that that patient would be better served on an ECMO circuit than, than on conventional ventilation.

So and those are well-established.

So but we are we are able to put those patients on a circuit early.

And that probably accounts for our 4 to 5 day, oh, really on the VV side or 4 to 5 day runtimes.

So Doctor Lasky, I have, a couple of questions for you because I don't want to miss the fact that you are UMC pediatric and associate adult trauma medical director.

So, all ages and let's talk about has there been a pediatric patient that has used ECMO and can you describe that?

And their tissues are a lot more delicate, etc., etc.. Because you were saying aggressive, but appropriately so.

Describe a time and what, what the the reason was to have a pediatric patient on ECMO We've who's lost a lot of sleep about this topic.

We're an adult trauma center that treats children and we go to all ages.

And we do that very well.

And we've done that for many years for very well.

Our ECMO program is adult centered.

However, some of our cannulas could go down, to someone, as young as 15 years old and or 40 kilo so and or 40 kilos.

It really depends on the the weight and and the size of 40 to 60, 40 to 60.

Yeah.

Okay.

So we're so we're looking at the, the weight of the patient, the age of the patient, the size of their vessels.

And there are some that we can help.

So we have had pediatric patients that were large enough, to come over to our adult surgical ICU and be cannulated there and managed care that we have put on ECMO, but that's not our goal.

We're an adult ECMO program.

But we're not going to miss an opportunity to help anyone in the community that we can.

Meanwhile, while our partners at El Paso Children's Hospital work for Toward their goals in their neonatal and pediatric use as they see fit.

Okay.

And is there a a machine, so to speak, or and I'm just trying to call an ECMO that's not an ECMO that can be used on no lower than 40 pounds of a person and describe what that is and maybe compare that to ECMO, since that's something that we're hearing about for the first time.

Well Ivan would know as much or better than me about.

Ok Ivan!

--But yeah, the machines are pretty much the same.

Okay, it's the size of the cannulas that differ, and it's the size of the cannulas that differ in the equipment that's used that that is different, to put in those cards.

So I know we talked about it earlier, but this is an hour long show.

Describe again a cannula.

I know we said at the very beginning, but again describe that.

And especially in this question, it's the size of the cannula that is different in one machine versus the other.

Yeah.

So if you can imagine sometimes women's vessels are smaller than men's and sometimes, well, most of the time children's vessels are smaller than adults.

And we often will look on the ultrasound and we can see is it the size of the thumb?

Is it the size of our cannula that we have, or is it too small for the equipment that we keep, in the competencies that we carry?

Because it's a it's an entire village of people we talked about it's critical care nurses.

It's respiratory therapist, it's ECMO specialists.

It's pulmonologists that predominantly take care of adults, that have a lot of knowledge of the heart on our team.

And then our surgeons who are adult trauma surgeons.

That may be very comfortable with, a child in a trauma scenario, but not so comfortable with some of these other, cannulation procedures in an activity, a child.

And that's more of the realm of the neonatal and pediatric doctors to, to work on those younger ones.

And.

Okay.

And so Ivan, take it from there on your end, because you are familiar with both as doctor, Lasky said, working with both machines when you said they're exactly the same.

Talk about some times that you used one machine versus the other, depending on the size of the, the individual.

And so the machine itself, which is the non disposable portion of of the system is exactly the same.

What changes can be the size of the oxygenating, the size of the pump use and the tubing used to connect to the cannulas as well as the cannulas themselves.

It's never the goal to insert a cannula that takes up the entire space of a vessel.

And so when you're dealing with smaller vessels, you definitely have to deal with smaller cannulas.

And some of them, are extremely tiny, maybe even smaller than the size of a normal pen, where we're used to, like Doctor Lasky said, garden hoses for for our adults.

The flow rates that are going through the system are also different.

So for an adult, you can you can safely get up to six and a half to seven liters per minute of blood flow on, on one of our systems.

In pediatrics, especially when you're dealing with, infants, neonates, sometimes your flow rates are, as low as maybe 200ml, you know, per minute or even even even, lower than that.

So we we've hit the point.

This is one of those things.

It's brand new to me.

So I'm asking a lot of just not personal questions, the questions that are educating me.

But we've got a whopping nine minutes left in the program.

So I want to turn things over to you all.

Stop questions for me, but talk about what you see in the next ten years.

What's ECMO going to look like ten years from now?

And I'd like for you, Doctor Lasky, to talk about that.

Also, on the pediatric side, what you see, the ability of happening for individuals that are weighted that just literally have smaller bodies and I don't know who wants to go first.

Doctor Mercer, would you like to go first?

Yeah, I think it's going to be relatively difficult to to predict where the technology is going to go.

And we're starting to see it.

Miniaturization on some devices, pumps and miniaturization and more and more efficient oxygenators that don't require necessarily patients to be in the ICU.

I'm not sure we're ever going to get to to a point where, well, we may, but it won't be long after.

I'm not doing ECMO that we have the ability to do this, in environments other than the ICU, where I see the big strides in ECMO in this community, in this region is our outreach, and it's the ability that we have to to go to the patient at another hospital.

And we've done that, taking the machine with you to another hospital, with us to another hospital, and put patient on an ECMO circuit, who is in extremis, cannulated them and and brought them back to, to, to UMC and ultimately in a rather ironic circum stance, we sent that patient back to bay.

I've seen the active duty military but a trooper or trooper brother so now terrible to ask for.

It's the obvious question is that person okay now?

Yes.

Okay.

Yes.

It's terrible for there was going to be a no no.

Okay.

But but I think system changes.

An expanding our program.

That's part of our strategy.

To that end, we, we have a, a large vehicle that's, that's custom configured for us to, to to to take all of our equipment and two pumps and multiple circuits, all of our staff to, to anywhere as far out.

It's about probably 45 miles.

cannulate And then transport back to UMC well, we're.

And the pump is working in transit Exactly, rather than then putting them in an ambulance, with really bad looking blood gases and the inability oxygenate those people and hope for the best hope they get here.

So that that that is a system improvement that we're going to see.

And then and I think that as we develop more technology, better technology, staying updated with the latest of oxygenators, of pumps and polymers that we use for our cannula in kind of where this is going to go.

So part of me almost wants to ask the questions like, who's the shopper that looks for the machines?

And you mentioned earlier and I don't want to bring it up.

So we have enough time.

But this is America, United States, but there there are, semblances of this in other parts of the world as well, depending on how that's going.

That's a whole nother show.

But I'm very curious about it, and I'm going to look a lot of that up when I leave, unless we can put that in for a couple of seconds.

So, Ivan, talk to me, because you've been around this for a long time.

Maybe what you foresee, but also what you wish could happen within ECMO So in my head, you're saying, Doctor Mercer, that to take this idea out of the ICU may not happen in your lifetime?

I think you're a lot younger than you think you are.

In my head, I'm thinking, could this be something that can, you know, be cost wise to have 2 or 3 of them in a hospital or maybe 2 or 3 of them in the city?

We start there.

Right?

And then going forward, is that something that you see going forward in the future?

We have five.

--oh you have five?

We always have a backup.

Okay.

All right.

Well, way to bury the lead okay.

I'm thinking there's this one.

This is one machine.

Okay.

Now taken to the fact that you have five.

Now, looking at that, just more reach and frequency, so to speak.

So, so I think with, with, time will come, not only the ability to, grow the program internally, but also to offer, outreach education to other facilities, other physicians, so they can know when it's appropriate to call us for a referral, to put a patient on ECMO And we're actively working on that now, but it's it's going to get better, and we're going to, put more resources into that, with the ECMO transport vehicle that, we're looking to purchase, the ability to, to not have to depend on, the infrastructure that set around, EMS right now in El Paso and be able to, you know, take off and, and cannulate a patient and bring them back, safely.

But, you know, you mentioned how maybe eventually, one day, we will start to see, ECMO outside of the ICU, and, and, there are, ECMO like devices, that can remove CO2 that don't require to have a specialist sitting in front of them.

You know, and, and I think that's going to be something that we may eventually see, for patients that may not quite need ECMO, but might need some CO2 removal.

Okay.

ECMO lite Yeah.

ECMO lite I like that.

I think all the things that we do now, like, supporting the heart, supporting the lungs will expand to other organs as time goes on.

I think we'll do more procedures under these oxygenated settings that we're able to create, with the ECMO cannulas.

And correct me if I'm wrong, it must start at in neonates.

Right.

And and children.

Oh and expanded to adults, which is interesting because a lot of a critical care started in adults and went to kids first.

We know it most started with trauma.

There was a motorcyclist that a bad pulmonary contusion and got put on a circuit and survived.

Now Doctor Bartlett, right.

Or this the guy in the 1970s, the early.

Okay.

The the early successes were in, you know, in neonates and their results are quite good.

I would would be remiss if I didn't say that our results in this program are actually quite good compared to the actual average, or participate in a registry call.

Also, I understand that is I always like the why to the was because I think I think we we set up a good program.

I think we trained our staff.

We've created policy frameworks that help us manage those patients.

And I think the fact that we have ECMO readily available 24/7, 365 means that a patient can go on a circuit when they need to go on a circuit and not when somebody runs something up to DC and, and we get permission in an aircraft, the availability of which depends on who in the world we're pissed off.

So it, it, it our results compared to the also live registry for VV there's just about 60% of their patients survive to discharge.

ours is currently 84%.

There's a lot to be said.

I love that you said that.

You have five units here.

And when you're talk about cross training, which is fantastic, and also looking at how the teams work together.

So thank you so much for doing that, Ivan.

Keep up the good fight.

I love that you did this eight months.

We had 12 months to do it.

Doctor Lasky, I hope to hear a little bit more about, how little bodies can.

When you said this is neonatal, you know, there's just that funny in-between population that's missing right now.

But again, this program has been called first ECMO program in the region, the team behind UMC Advanced Life Support System, and again, ECMO, because when I had to look at it 3 or 4 different times because it's also not, easy to pronounce, it's the extracorporeal membrane oxygenation.

Again, it it works kind of as an artificial lung and an artificial heart at the same time.

So I want to say thanks so much for you all being here again.

This program is underwritten by University Medical Center.

But also truly the ECMO program is in partnership with the Texas Tech Health El Paso, as well as, the University Medical Center.

And if this is a program that you are interested in and just found, this last minute, you can go back online and look at this at three different places.

You can go to PBSElPaso.org You can also go to the El Paso County Medical Society website.

And that is EPCMS.com and then also youtube.com.

And again just put in there the El Paso Physician And usually the latest show that was aired on PBS El Paso pops up.

But if you're interested in this again, the title of this program is first ECMO program in the region, ECMO.

Thanks for joining us.

This has been the El Paso physician.

I'm Kathrin Berg.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso Physician Television program to your home for the last 27 years on PBS El Paso.

If you should have any medical questions relating to this program, you may email us at EPMEDSOC @ aol.com.

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