JUNE 23, 2020 – A specialized team from Brooke Army Medical Center virtually supported a heart-lung bypass on the West Coast, saving a Soldier’s life and marking a first for this lifesaving program.
BAMC teamed up with Naval Medical Center San Diego last month to administer extracorporeal membrane oxygenation, or ECMO, treatment to a patient with presumed viral myocarditis, an inflammation of the heart muscle which can, in some cases, lead to heart failure.
“This was BAMC’s first time virtually supporting ECMO and it was highly successful,” said Colleen Mitchell, ECMO primer, Institute of Surgical Research Burn Center. “It is a game changer for critical care.”
Physicians first pursued conventional therapy when the young active duty Soldier was admitted to the Naval medical center. However, with the Soldier’s condition declining, all signs began to point to ECMO as the best course of treatment.
ECMO is a heart-lung bypass system that circulates blood through an external artificial lung, oxygenates it, and delivers it back into the bloodstream. Rather than treat the condition, ECMO performs the job of the patient’s heart and lungs, buying the patient precious time to respond to treatments and heal. Established in October 2012, BAMC has the only adult ECMO center with full capability in the Department of Defense and remains one of the few centers in the world with air transport capability.
“The sooner the patient is on ECMO and stabilized, the less time vital organs are without oxygenation or necessary blood pressure support and the quicker the recovery,” said Bernadette Elliott, Adult Extracorporeal Life Support (ECLS)/ECMO Transport Program Manager.
With increasing evidence of its lifesaving properties, in recent years adult ECMO has become a hot commodity around the world, and other military medical centers have expressed interest in the capability. Naval Medical Center San Diego was one of the first military hospitals to purchase ECMO equipment that would enable short-term care prior to a patient transfer, noted Lt. Col. (Dr.) Robert Walter, chief, Pulmonary/Critical Care Medicine.
Last December, a team of BAMC physicians and nurse specialists flew to the naval center to provide training in ECMO administration, patient transfer, and telemedicine-based mentoring to 25 personnel.
“Fast-forward to now, and that initial training was incredibly beneficial,” Walter said. “With the patient in this case clinically declining, the physicians in San Diego were able to recognize at a critical moment that ECMO was indicated and feel confident they could provide appropriate care.”
In close coordination with the San Diego-based team, BAMC offered to virtually assist with cannulation, which is the insertion of tubes into a patient, and other ECMO management as the center coordinated a patient transfer to a local hospital.
In the absence of a specialized team and full capability, the aim is for military medical professionals to have the skillset to stabilize patients on ECMO for transfer to a local facility for shorter-term care, such as in this case, or flown to BAMC when a longer course of treatment is indicated, which is typically the case with illnesses such as influenza, Walter explained.
Mitchell was the primer on call at BAMC the day the call came from San Diego. The primer is responsible for ensuring fluid is smoothly flowing throughout the circuit.
“We tried to connect via secure video teleconferencing; however, there were technical issues so we defaulted to audio support,” she recalled. “I walked them through cannulation and priming the circuit, while closely monitoring the patient’s vital signs. It went very well.”
The Soldier was successfully transferred and removed from ECMO after a few days and is expected to fully recover, Mitchell said. “There’s no better feeling than to have the skillset needed to contribute to someone’s survival,” she said.
“If that capability hadn’t been there, there may not have been a good outcome,” Elliott added.
Teamwork was key to this success, Walter said. “This was a terrific example of collaboration across facilities,” he said. “And it was one of the most avant-garde telemedicine application I’ve seen. There’s nothing in medical literature regarding virtual support of adult ECMO cannulation and management. BAMC is truly at the tip of the spear.”
Further down the road, Walter said the team hopes to become the hub of virtual ECMO support to other military medical facilities around the world, providing tele-mentoring and virtual biophysical monitoring of patients both stateside and downrange.
The goal is to have consistent, quality ECMO care and capability throughout the Military Health System, said Elliott, noting that BAMC can fly a patient here from a combat zone in 18-36 hours. “Whenever we hear a patient is alive today because of our support … that is what it’s ultimately about. It’s real-time critical care support.”
By Elaine Sanchez