All right, everybody, let's get started. My name's Julie Winkle. I am one of your Board of Regent Representatives, and I'm Chair of the Fellowship Services Committee. I want to thank you for coming to the American College of Critical Care Medicine ProCon. We have four wonderful speakers today, and again, I thank you. Our first topic is about burnout and wellness, and it's interesting to have a ProCon debate about wellness. It's not like you're going to have somebody who's con against wellness. But what we've heard so much about wellness, but we don't really have a lot of strategies or a lot of discussion about whose responsibility is it. So we have two speakers to talk about our first topic, which is wellness. Our first speaker doesn't need any introduction at all. He is a past president of the Society of Critical Care Medicine. He's a charter member of the American College of Critical Care Medicine, an icon in pediatric critical care. But more importantly, and the reason that we really wanted him to speak on this topic specifically, is through his practice, through his demeanor, through his mentorship over his career, he seems to epitomize everything you think about wellness and work-life balance and the kind of physician and human being that we all want to strive to be. So thank you, Jerry Zimmerman. Thank you. All right, are you ready for some rock and roll? Small, intense group, right? Okay, we are going to head this off with the session is a Janice view of wellness, you know? Could be two sides to this issue, nature, nurture, whatever. I'm going to convince you that the environment is ultimately important in this question. And I'm going to argue for a specific type of environment called a learning healthcare system. And if you were at the plenary lecture this morning by Gordon Bernard, you have an introduction to what a learning healthcare system is if you're not already familiar. I don't have any disclosures. So let's talk about this idea of a learning healthcare environment or system. And I would say as a starting point, this is the, I would say this is the textbook for this discussion that we're going to have today. If you haven't seen this, this is a publication by the Institute of Medicine that came out at the end of last year. It's long, it's detailed, it has every reference that you'd want to know. It's free by downloading it. So if you need the reference later, just let me know. So in this document, there are guidelines for developing well-functioning systems. And these systems function within the environment that we might work to promote a wellness environment. So first is enhancing the meaning and purpose of work and delivering value to patients, providing adequate resources and environment so that there is the resources needed for clinicians to do their work in the best way. And then to design work systems that encourage and facilitate relational care, as they call it. In the ICU, we call it teamwork, and nowhere is this more important teamwork than in the ICU. Collaboration, communication, and professionalism. So there are system work factors that really promote wellness within this environment, and they are summarized here. Create positive work environments, positive learning environments, reduce the administrative burden, make the electronics and the technology actually work for you instead of against you, and provide support not only to the people at the bedside, but students and all types of clinicians. And then there's an interesting one right there at the end, invest in research. So this leads me to the point that this sounds a lot like a learning healthcare system. This is also a product, a former product of the Institute of Medicine, and a learning healthcare environment is one in which clinical care and research, including quality improvement and a shared education model, these three elements are so related, intertwined, connected to each other that when it works, they're basically inseparable. Each one of these elements informs and benefits the other. So this is a schematic presentation, a depiction of this idea. This structure, this environment cannot exist without a foundation of professionalism. And if I'm getting too personal, too individual, I'm sorry. But where I come from, when we look at people who are getting promoted, you may be a great researcher, you may be an outstanding clinician, you may be a wonderful teacher, but if you don't have professionalism, it stops there at the promotion committee. So it's hugely important in this environment, learning healthcare environment. There's three pillars that support this learning healthcare environment. The first is the best clinical care. The second is clinical research that is conducted within this environment. And this includes, importantly, quality conducted, quality improvement, and the last is this idea of a shared, not siloed, educational model. So let's talk about professionalism just for a bit. The Institute of, no, I take that back. Where I come from, professionalism is an art form. So it's not only the individual, as you can see, but how this individual works within the environment. So starting off with A for accountability. There are things that are particularly important, I think, in medicine and critical care. The first is providing value-based care, choosing wisely, EG. The second is demanding a culture of safety, because this complex patients, complex therapies, complex environment, perfect storm for errors to occur. So everyone demanding this culture of safety. The second, R, is respect. This means inclusion. This means diversity. And this whole idea in respect is really to embrace this idea of wellness, not only for yourself, but for the entire team within this environment. And last, there it is, teamwork. And this is not just, you know, the doctors and the nurses getting along. This is also acknowledging that that patient and that family alongside the bed have to be part of this team. And that there's other people, too, educators and the researchers, the people working in quality improvement who are trying to lift the standard of care up. And then celebrating that all of these elements in the team are important. So in this report from the Institute of Medicine, they list personal factors that can promote wellness. You're going to hear about this from Shelly. But they also spend a lot of time talking about the importance of environmental factors. And here they are. The right culture within this institution. There is professionalism, again, and having systems that promote and demand professionalism. And then there's this last category under this section. And this is the characteristics of the practice. So now I want to talk about what I think are the important characteristics of this practice in a general way. But here they are. Then the first one is practicing best care that is available. So this idea of clinical standard work or a pathway or an algorithm, if it makes the hair go up on the back of your neck, I'm sorry. But there's no question anymore that this is a valuable concept in clinical care. So these are the characteristics of clinical standard work. They're conscientiously developed by a team, including all stakeholders from the very beginning. They are evidence-derived when possible. And when there is lack of evidence, you get the stakeholders together and you develop a consensus. People at the start agree that we are going to follow this. This may not ultimately be the right way to do it. But it is a way that we can do it. It's owned by somebody. And if that doesn't happen, sustaining this will never work. And as I said, it describes a pathway or a trajectory of patient care. It's measurable with patient-centered metrics. And it really represents the basis for improvement. So this idea of standardizing things, first of all, it will eliminate waste. It will improve communication between the team because everybody will be on the same page. As I said, it is the basis for continuous process improvement. And what this is really doing is eliminating a lot of noise and nuisance variables in the system. Because without standardization, there's really no way to rationally measure improvements in the care that we deliver. So the best example I could think of this, at least in pediatric critical care, is CLABSI. And as you know, CLABSI was a big deal. It's still a big deal. And it's associated with lots of bad health outcomes, increased duration of stay, more antibiotic therapy, means you have to have an IV in place, increased morbidity, increased mortality, and this adds cost and decreases value in the system. I remember when I started critical care, people said, oh, these patients are critically ill. Of course they're going to get infections. It's just kind of inevitable. And nobody even washed their hands. Actually, when I first started, people were still smoking in the hospital. So we have made some progress. But in 2006, a national collaborative, this was a pediatric collaborative. There certainly were identical adult things going on. But in 2006, a national collaborative of many hospitals got together and said, we're going to, we're going to tackle this problem. And we're going to develop clinical standard work for best practice for central venous catheters. And what they found was over a five-year period, the incidence of these central line associated bloodstream infections were cut fourfold. This is huge. And it was because of derivation and then people following a bundle to put in these catheters and then a bundle to maintain them. And I would say it is possible that this intervention right here has saved more lives, decreased morbidity, and saved more cost than anything we have ever done in the pediatric intensive care unit. So this is an example of standard work that has been introduced and sustained. So the second pillar on this house or environment of a learning healthcare environment is clinical research in the standard sense that you think of it, but also really good quality improvement. So I just want to quote Claude Bernard. I guess you people consider him the father of physiology. And he once said that people say that medicine is the art of healing, but wait a minute, shouldn't we be saying that medicine is the science of healing? Because after all, wouldn't it be nice if we could arrive at a cure scientifically instead of empirically? This is the charge of why research is important to all medicine, critical care as well, of course. In our ICUs, I would argue that there is no better place in the whole hospital in terms of clinical stimuli in need for investigation to improve practice and outcomes. So at the same time, we now have people working in the intensive care unit like our trainees coming in are better educated. They know more about medicine. They know more about science than anyone in the history of medicine has ever known. And this is ripe. This is the right setting for fundamental discoveries, and so why not in the intensive care unit? So traditionally, research that we think of is focused on patients. That's where most of our research effort has gone. More recently, people have also stepped back and said, whoa, you know, the people at the bedside helping this patient are also important. For example, if you're a family of a child with a serious illness or injury in a pediatric intensive care unit, half of those families are going to have post-traumatic stress disorder six months later. But then the newest thing is doing research on how we actually deliver the care. So surviving sepsis and what happens long-term after is not just how we deal with the infection and the inflammatory response, but it's all the other things that we do to this patient while they are critically ill. So I cannot pass that without talking about ICU liberation, which I would define as clinical standard work for our usual care in the ICU. Anybody that's sick can benefit from this, child or adult. And here are the elements of the A-F bundle. Prioritizing pain control. Undertaking scheduled weaning of the ventilator. Weaning of the sedation every day. Being cognizant of the choice of drugs that we use for sedation if we are going to use sedation. Avoiding benzos, for example, because that is associated with delirium. And delirium is associated with every bad outcome, including death, that you can think of. Getting these patients mobilized a little bit or a lot as best we can, and then empowering and engaging the family in the care plan. So in 2019, there were, I would say, two blockbuster articles that appeared relative to ICU liberation. If you haven't seen them, I'm going to summarize one of them for you. On the axis, the Y-axis, is the proportion of these six bundle elements that were actually practiced or employed in a patient. And then on the X-axis, three different clinically important outcomes. Survival from the ICU. Survival from the hospital. And risk of death. And just look at these effect sizes. These hazard ratios. This is how we do our care in the ICU. And these hazard ratios are bigger than any interventional trial I would think that I can think of that has ever been done in critical care medicine. And in the summary of this article, this second article, the investigators point out not only decreased risk of death, but fewer days on the mechanical ventilator. Actually, less need for restraints. Decreased risk for ICU admission. And when you leave the ICU, you have a greater chance of going home as compared to being admitted to a nursing facility. So lastly, this idea of an interdisciplinary education model. And no place, again, more than the ICU does this kind of foundation hold that everyone's a teacher as well as a student. This idea of not a siloed, but an interdisciplinary model for education has lots of important characteristics. It encourages development of teamwork. It provides realistic simulation with everybody. It allows people to experience other people's perspective. Leads to tolerance and respect. It facilitates complex communication practice. And for adverse events, communication is always right up there on top of what went wrong. It encourages patient and appreciation of the patient and family perspective. It encourages trust and sharing and power. Power sharing and increased value. And it really promotes this idea of systems thinking. So if you have or if you do CPR and you are going to transition this patient on to ECLS, when you are practicing this, the nurses can't be doing it over here. So the respiratory therapist, the bedside nurse, the charge nurse, somebody taking care of medications like a pharmacist, the ICU physician, the surgeon, the pump techs, the respiratory therapist, everybody needs to be involved in this interdisciplinary education model. So summing up, on the left upper corner are these concepts of the environment. And if you can't read it, it's the external environment, the healthcare organization itself, and the frontline care delivery. And all of this stuff focuses or filters down through the individual. And we're going to see how more about, hear more about the individual in just a second here. But ultimately, the balance here, how this all works will influence the tipping towards wellness or the risk of clinical burnout. And the consequences are not only for the bedside providers, but for the patient and society as well. This all can feed back on itself. But my point here today is that this environment ideally is a learning healthcare system that will benefit not only the patient, but the people providing the care as well. So in closing, there are three primary pillars or elements to this learning healthcare system. Patient care, the best we can determine and deliver a shared education model. And lastly, promoting clinical research, including quality improvement in our units. Lastly, fostering this learning healthcare environment, the reason that it works well, for example, in hematology oncology is that it really facilitates the identification and then implementation of best practice. But the other thing relative to our discussion today is that it promotes wellness for the community of ICU providers. Thank you very much for your attention. Thank you. So in a totally different perspective on wellness, I am pleased to introduce Dr. Shelly Dev. So we really tried hard to get Dr. Dev here. And it's my apologies that she didn't make it into the app and the program. But she comes to us from Toronto. She's Director of Education in the Department of Critical Care Medicine at Sunnybrook in Toronto. And she runs the education program for both the residents and the fellows. She has an interesting history in that she specializes in creating diverse multimedia education tools. She actually works with the New England Journal of Medicine and a lot of their video creating content. But really the reason we asked her here is because she is an incredibly gifted speaker and has received not an uncommon amount of standing ovations for her talk on wellness and burnout. So Shelly Dev. I like that you've been instructed to stand at the end. That's so funny. Thank you so much for the invitation. I just, it's been really nice to be here because this morning I overheard a woman in the lobby of my hotel exclaiming to her friends who wanted to sit outside for breakfast that it's 87 degrees and I'm not going out there. And please know that it's 36 degrees Fahrenheit in Toronto where I'm from. So I'm furious that we're inside. Now given that I am speaking to the idea that well-being is the responsibility of the individual, it would not be unreasonable for you to expect that I may spend my entire time up here leading you in a guided meditation while wafting essential oils and sprinkling you with chia seeds. That's not what my time up here is about. I'm here as a fellow worker who is tired in a way that I think we should all be. We should all be tired of waiting for solutions to be proposed to us by institutions when the very crisis we are discussing is so deeply personally experienced. An encounter I had with a colleague a while back made this very clear to me. It was a few years ago that I was on call in the ICU in Toronto and I was walking into work and it was early morning and I had my entry coincided with that of a colleague from the Department of Surgery. And we began to exchange pleasantries. Hi Shelly, how are you? Oh, I'm well, how are you? And he said, I don't know. Which is a strange thing to say. And I asked him what he meant by that. And he says, I'm not good, things aren't good right now. And so I stood there and I probed further and he told me about an interaction that he had recently had in his clinic with a patient that he'd been following up for the last 10 years. So this was her annual well checkup and they were done and he said, okay, see you next year, it all looks good, just book your appointment for the next year on your way out. And she said, would you please sit down? So she asked him to sit down and she closed the door and she faced him and she said, you're not the doctor you used to be and that's too bad. And then she walked out and she left and she did not make a follow-up appointment. And he was absolutely gutted by this. And we talked and as we talked, it became clear to me that things had not been going well with him for quite a while. And this interaction with this patient was not the first sign that things had been going poorly for him, but it was the most recent sign. He had been struggling with health issues, not sleeping well, gaining weight. He had been having difficulties with relationships within his family, with his partner. There was a lot of anger and frustration that was mounting and he had been considering seeking therapy or time off for quite some time. And we talked about that. And he had probably been thinking about this for at least a year, but it was the patient interaction that really freaked him out. And initially I was so struck by this, but the more I thought about it, it made perfect sense to me. For as long as any of us can remember, we didn't call this kind of behavior what was happening to him, burnout or unhealthy work habits. This is what we call capital P professionalism. It was getting your work done and doing what was expected of you, no matter the personal cost. Suck it up, leave it at the door, do your work. I have heard myself say these things. It is important for us to recognize that the foundation for our unhealthy choices was being laid for us the moment we started our training and it stuck. Once we become practicing physicians, we continue to propagate the most cruelly and consistently perpetuated myth in our world. That is nothing you do or see around here should bother you if you're worthy of being here. And if it does, there is something wrong with you. What else can we call this other than an imperative to conform or to cope in any nefarious way like a good capital P professional should? And here we are now contending with a very real threat to our own health and longevity within the very profession we contorted ourselves around to serve, so capital P professionally. My only disclaimer today is that it isn't a stretch for me personally to consider our burnout crisis in medicine from the perspective of the individual. I first engaged in this discussion from the purview of my own personal struggles. From the moment that I first spoke and wrote about it as such, my life was overtaken by hundreds of similar stories shared with me by fellow healthcare workers all over the world. I was dumbfounded by how similar, common and widespread these stories were. And that's when I realized it was crucial for the central focus of discussions on burnout and wellbeing to shift to its rightful place from the deeply personal to the powerfully communal. There's a phrase in a book that I read a few years ago that I loved called The Knicks. It's by an American author named Nathan Hill. And he has a phrase in there that perfectly captures where I think we are in all this chaos. He writes, sometimes we're so wrapped up in our own stories, we don't see how we are merely supporting characters in someone else's. Think about it. We are unwittingly a community of individuals privately struggling alongside one another in parallel. And in keeping our unknowingly shared pain private, hidden and shuttered from one another and not choosing to step out of these parallel lanes to instead opt to intersect, we are missing opportunities to direct the course of our own community's recovery. We have become so accustomed to carrying on the punishing tradition of stoicism, the suck it up model of professionalism. We have rendered our pain invisible and our perspectives unheard within important discussions that affect our day-to-day lives as frontline healthcare workers. These are crucial discussions that are happening at the leadership levels of our institutions, at the top. And we wait at the bottom for solutions to trickle down to us, solutions that are at best marginally informed by our personal and individual and communal input as workers. How is it that we have resigned ourselves to this singular reductive model of change for so long? How can we possibly be satisfied with this? To further illustrate what I mean, I will draw from the well of accidental wisdom that emerges from the deceptively innocent and irritating chaos created for me by my beloved sons, Nathan, who is 11, and Jack, who is 10. Recently, one morning before school, Jack was convinced that Nathan was making fun of him. After his limited attempts at reasoning went nowhere, Jack decided to resolve the situation by throwing a tube of toothpaste at his brother's head. When my husband and I intervened at this point, Jack tried to assuage our anger by reporting that the toothpaste didn't hit him, I missed. As we began explaining to Jack that attempted manslaughter would still be punishable by time in prison, Nathan piped into the discussion with an all too unhelpful, but no less emphatic, yeah, Jack. Natie, I said, please stay out of it and let me and dad deal with him. It doesn't help when you interrupt or interfere. Nathan, finding this outrageous, says, mom, I am a key stakeholder in this argument. Now this kid, I must explain, has always leaned towards the dramatic, but his insistence here moved me. He insisted on engagement rather than resignation because our ruling as parents on the situation would affect him personally. Why on earth would he want to sit on the sidelines of a decision like this? I know we aren't school-aged children and I sincerely hope no one here has been clipped by a tube of Colgate, but this tension between engagement and resignation is one we full-grown healthcare workers are contending with every day. When we are so genuinely engaged with our desire to give our best to our patients, why are we so resigned to the belief that we have no ability to markedly impact the very workplace in which we try to achieve that end? Why on earth are we on the sidelines waiting to see what happens? We need to start changing the way in which we envision change itself, and we need to start now. And not in waiting for top-down solutions to the crisis our community is dealing with. We are not only growing more cynical and frustrated, we are missing chances for meaningful workplace change to be initiated by us, the workers, from the ground up. We cannot, and we must not, wait to be told what our workplace should look like and what it is that we should value. Our workplace, our community, must be shaped by how we choose to define our values and how we relate to one another as the workers. I think we can learn much about the values we do aspire to by considering a recently much-buzzed-about topic in workplace conversations and in written thought pieces, the disappearance of the physician lounge. I have lost count of the number of times this was raised as a lament among the numerous different physician groups I have spoken with over the last few years. Why is this so interesting right now? Do we suddenly feel the overwhelming need to have more fridge space or heat up our leftovers? Of course not. This lament is an argument not just for physical space, but for communal space. And I completely agree with this pursuit because space, my friends, is the solution to our current crisis. It's space. This may seem far too simple an answer to be sufficient, but that's only if we narrow our understanding on what is meant by space to begin with. There is much to be mined here, if you consider it, but first you'll have to permit me a seeming non sequitur. There was a time when my birthday would roll around and gifts from my husband would have these similar lovely themes. A surprise trip with my best friend, a day at the spa, a staycation in the city, all these wonderful little getaways. As the years wore on, my understandably now weary husband would feel the ongoing pressure to keep up this theme. There would be an extra layer of pressure because I will admit I love my birthday to the extent that I am deeply annoying about it. But at some point along the way, my answer to his fatigued, okay, Shel, what do you want for your birthday this year, would be the same every year. I would say, I want to have a nice day in my own home. I don't wanna go anywhere to feel good. I want to feel good right where I am. It hardly seems celebratory, but consider a day wherein your only objective is to enjoy being in your home. I would read in the armchair in my bedroom. I would cook whatever I felt like cooking in my kitchen without any time constraints. I would watch a movie in my family room. I would wait for the sun to set in my backyard, and I may even allow my family to stay in the house. It's remarkable how the same house that holds bills on the counter, dirty clothes on bedroom floors, and dishes in the sink can be the very space that allows you to experience gratitude, peace, laughter, and inspiration. That's because space is more than a physical construct. It's an emotional one. This holds true for all the spaces we occupy for significant periods of time, like at home or at work. The very same wards or nursing stations or hospital rooms or hallways can go from feeling constricted, demanding, weary, and foreboding, to familiar, bustling, productive, and joyful. This concept is what clinical psychologist John Wellwood over 40 years ago termed our lived space, made up not only of what we see and touch and physically engage with, but our feeling space, how we emotionally experience what is around us. When we feel joyous, Wellwood writes, space is light and expansive. When we are sad, space is heavy and oppressive, seeming to press down upon us. It is imperative that we appreciate the possibilities embedded in this construct, that the very workplaces we currently associate with stress and frustration can come to be associated with thriving and community. The seemingly sudden interest in bringing back the physician lounge is not about workers wanting a place to eat. It is a manifestation of our valuing our workplace as both a physical and felt space. It's about wanting a place to joyfully coexist. We want to feel connection, friendship, support, and allyship with one another. And we don't want to go away to feel these things, we want to feel it at work, right where we are. Yes, there are systemic challenges we must wrestle with daily, and we must devise tangible, reachable strategies to deal with these obstacles in our quest to create more healthy and functional workplaces, as Jerry has presented to us. But I promise you, there will be no traction, no lasting impact of any systemic interventions, and no changes of any significance to us personally if we do not first reckon with our ailing workplace culture, so desperately in need of rehabilitation. It is time for a cultural revolution and a reframing of our values, and we the workers must be purposefully engaged in that reframing, because it is us who will work within the system that enacts these values. The anthropologic definition of culture is the system of shared beliefs, values, customs, and behaviors used to cope with the world and with one another that are transmitted from generation to generation through learning. The key word in the definition of culture that we overlook is shared, a system of shared beliefs, values, customs, and behaviors. We all not only exist in this culture, we are responsible for creating it. In looking at how we work today, how else would our culture be described other than one where outcome is valued over process, one with an abiding commitment to getting things done, regardless of personal cost? We have played a part in the creation of this crisis by not appreciating how much we control it and how much we can fix it by redefining what it is that we value. By now, the connection between health and well-being of the worker and the ability to provide high-quality patient care can't be ignored. By investing in ourselves as a community, we are investing in our commitment to our patients to provide them with the best care possible. The way we get there is by remembering that we are a community not just of individuals, but of colleagues who are fellow human beings. We must genuinely and tenaciously look after one another. We need to talk, we need to listen, support each other, we need to look at the people that we are worried about and ask the key questions, are you okay? If we make difficult experiences safe to talk about, more people will talk and then more people will ask for the help they need, whatever that is. When I first told you the story about my work colleague, I omitted some important details about our relationship. I didn't tell you that beyond our having shared maybe less than five patients in over 15 years, we don't know one another at all. We know nothing about each other. We have never talked socially, we have never met socially, I don't know where he grew up, he doesn't know those things about me. We know nothing about each other's lives. So I find myself thinking, why is he talking to me and confessing to me the details of this deeply personal crisis? And then it hits me as it has so many times in the last now three years, when so many similar conversations have caught me off guard. He's telling me about his struggles because he already knows about mine. He's heard me talk about it, he's seen me write about it, he knows it's safe to do this because he already knows, I'll understand and he already knows I wouldn't judge it. Because from his point of view, I did something we could all do immediately in our own places of work, which is go first. In medicine, the opportunities to lead are abundant. There are few moments when we aren't leading a clinical team or a committee or a teaching session or a department. But as colleagues, we must recognize the most meaningful, impactful way of leading is not at the head of a table or in front of a crowd. It is in vigilantly identifying every opening to go first, reaching out, connecting, listening, or even sharing our own stories of struggle. It starts so simply with a single offer for coffee, a text to see how things are, an email to check in, a genuine invitation for someone to answer truthfully and fearlessly. I know I could not have been primed for my own opportunities to go first without someone else doing it for me when I desperately needed it. I've spent the last few years attempting to galvanize my fellow workers into considering how much we as individuals within the culture can move it forward by being the colleagues that we want to work with, by embodying those behaviors we seek in one another to create more supportive and connected workplace relationships. This has been central to my focus to spark change from the bottom up. And the interest and enthusiasm for this by colleagues and trainees of all walks in healthcare has been inspiring. But this is not sufficient to move the dial. There is an essential, unavoidable, elephant-sized caveat in the room that we must confront. In agreeing that supportive and compassionate collegial relationships is essential to a healthy workplace, to our thriving as professionals, and to our being able to provide the best care to our patients, then we must also agree and mandate that our leaders, at every level of leadership, personify and uphold these shared values. And if they don't, we must have the moral courage to reconsider their suitability for those deeply influential and advantageous positions. This may sound audacious. Perhaps it even comes off as scandalous. Both are objectives I would warmly welcome in my eulogy. Pointed as it may seem, we must be willing to face the fact that our backward notions of what constitutes capital P professionalism are breeding, truly, on professional behaviors. Professionalism is not sucking it up and getting the job done. Professionalism is not about outcomes. It's about process. It's not about the work we get done. It's about how we work, how we behave, and how we behave with one another. This requires a certain self-awareness, knowing yourself in terms of all the variables affecting how you feel at any given moment and how that impacts your work and interactions. Regardless of how any well-meaning governing body or position paper may seek to define it, the enactment of professionalism in the medical trenches has much more to do with ends and far too little with the means. A professional as we know them delivers. Process, how he or she goes about it, matters very little in our world because the outcomes are too shiny to refuse. We prove this point with every utterance of, yeah, but X is a great surgeon. Or, well, Y does bring in a lot of grant money. Or, that's just how Zed has always been. You'll get used to it. We all have. We allow all sorts of lapses in process, meaning actual professionalism, not just in the day-to-day of work, but in the loftiest levels of leadership, all in the name of great science and apparently unmatched brilliance. And most problematically, we confuse these lapses for quirky and eccentric leadership styles rather than recognizing them for what they can be if left unchecked, harmful, alienating, oppressive, especially for the most vulnerable among us, our trainees and junior colleagues. Isn't this the same age-old debate that has thankfully reemerged with gusto in larger society today? That is, should we separate the art from the artist? And if we did, how could we possibly fathom an existence with all that lost art? This is a question that arises purely to contend with whether bad behavior is excusable when manifested by someone we have collectively anointed as singularly skilled or talented. Isn't it time we reckon with the invisible other half of this question? What about the art, the potential, the offerings we never experienced because of those emerging talents that were marginalized by these behaviors? We as a society have always prioritized rigidly defined success and plaudits over character. Let's acknowledge our own mess in our own house before passing judgment on the housekeeping of others. Are we so different in our micro society of medicine? Haven't we commodified publications and academic fame as assured pathways to job security and leadership? Do we require those leaders to set a standard for collegiality, patient advocacy, and workplace civility before we award those positions? Do we insist that they possess the skills of emotional intelligence to benevolently inspire and support others when we recruit them? Do we promote on the basis of collegiality and civility and respectful practice and career mentorship in the same way we do scholarly productivity? No, we don't. Because I assure you, if we did, the problem wouldn't be as big as it is. But we today can choose differently. We can choose to reject the shiny for the durable. We can choose to be done with resignation and opt for engagement and pull up a seat to the table. We can importantly shift our culture in the right direction as individuals who are part of a community of colleagues with a shared vision for a healthier workplace that is defined by, one, our authentically connected work relationships and going first when we can, and two, our exemplary leaders who uphold these values. Our patients will do better if we do better and if we do better by one another. We are all key stakeholders who become impossible to ignore and overlook if we draw on our own experiences and perspectives as workers and insist on engaging in this dialogue. All I can ask today is that you each consider the part you can play in this shift, this movement that begins with the personal and makes its way towards the shared and the communal. It may well be time to step off the sidelines and see what happens. And after that, I will be happy to bury you and all the chia seeds of any color at your request. Thank you. All right. We're going to leave questions until the end. We're going to take a total switch on our topic. I would like to present our first speaker and our second topic. John Marinaro is slowly taking over the state of New Mexico, one provider, one hospital system, and one patient at a time. He's a professor of emergency medicine and critical care. He is co-chief of critical care for the University of New Mexico Health System. And he is director of the ECMO program for the University of New Mexico. So thank you, John. Thank you, Julie. I appreciate that. Hi. You know, it's wonderful to follow these two great orators, the father of one of the fathers of critical care and one of the mothers of professionalism. And I'm kind of the weird uncle of pre-hospital ECMO. So we've got the whole family here. So today we're going to do a little pro-con debate. And I don't know if it's necessarily going to be a true debate. But we're going to talk about pre-hospital ECMO. And one of the reasons why is my group was the first in North America to do pre-hospital ECMO. And we did it starting last September. We've had a program going since then. So how do I advance the slides? There we go. So I have no disclosures. A little bit about my bias. So when you ask me, when is ECMO too much, that may be, I'm not the greatest barometer of that. So I have a cat named ECMO. And you notice the cat. He's got kind of a screwed up eye on the left there. And if you think about it, you have to be a little screwed up to want to do eCPR and pre-hospital ECMO. So the cat works well for us. My Christmas tree ornaments was a quadrox oxygenator as the top of my Christmas tree. So again, a little biased. Around the hospital, everywhere, they have the evolution of ECMO video going, of course, which I'm there. So my bias is here. I'm a little bit pro-ECMO. So we're going to talk about cardiac arrest. So 350,000 patients suffer cardiac arrest in the United States each year. It's a huge amount. And the average survival on that, all comers, is about 8%. VTAC, VFib patients, they have about a 30% survival rate. But the PEs and PEA and asystole, with all comers, it's down to about 8%. If you look at typical cardiac arrest, about 70% of them occur in the home. About another 20% occur in public settings, such as supermarkets, et cetera. And then the rest can occur in nursing homes. So what we have to do is we have to start really thinking to ourself is, how can we save more lives with cardiac arrest? Because there's just a huge amount of people dying and such a poor outcome, despite all we're doing. So prolonged cardiac arrest even has a more dismal outcome. After about 20 minutes of CPR, less than 1% of people come back neurologically intact. This was a study that looked at that. And as you can see, out around 18 to 20 minutes, survival is dismal for neurologically intact survival. So it's time for us to try to start thinking, how are we going to change this dismal outcome? There's the AHA chain of survival. I actually am starting to do a talk called Cure for the Common Code. And the Cure for the Common Code is that we need to change our little survival chain that we have. So there's early recognition and activation. I just got back from the Canadian Critical Care Conference, where a guy from Edmonton did a wonderful talk on, he searched all of the videos out there on cardiac arrest. So the YouTubes, the Vimeos, and all the other programs out there people can upload. And went through and looked at what everybody was presenting to on the closed caption TVs of cardiac arrest. So you'd see people stumbling down the street and collapsing. And then there would be people who were hunched over if they were on the basketball court. Or there's people, the amount of people were just touching their face or their neck just prior to arresting. The ability to early recognize and early activate EMS is so important. And he's hoping to come up with some data that can help kind of stir what people are looking at. The other thing that's interesting is the amount of people who cardiac arrest who keep spontaneously breathing. It's well over 30% for prolonged periods of time. And people miss that. And so they don't really activate as well as they could. So the first chain of survival that we could really work on is improving ability for everybody to recognize when people are cardiac arresting and then activating EMS. Early CPR, fourfold at least increase in survival based on some of the studies. But it's very good CPR really will help. The ability to have Lucas compression devices so people can get transported more, very important. Early AED, and I know we have Paul Pepe here. I don't know where he went. But one of the early AED guys. Clearly, clearly a benefit. And that is why we're getting the survivals we have in VTAC and VFib. Interestingly enough, though, that's where it dies out. ACLS, which is the fourth link in the chain by American Heart Association, really is not showing to do all that much. Most people are saying epinephrine's probably bad for you. A lot of people, the OPALS study came out basically showing that ACLS does very little to add to the chain of survival. So what I believe that we should do is to start thinking about how we can change that chain of survival and adding eCPR into that. So ECMO for salvage therapy and cardiac arrest has become fairly ubiquitous. Currently, again, 8% to 9%. We're up to about 30%. Yiannopoulos in Minnesota is publishing up to around 50% survivability. On the general, I think in his latest paper, he actually has 100% survivability for VTAC, VFib within 30 minutes. Again, that's a little bit easier population to get some people back with. But ECMO has really become what everybody believes in. So who are the high-yield cardiac arrest ECMO patients? Patients with witnessed arrest. If you just find a person down, they're not going to be a good candidate. But a witnessed arrest patient is a great patient for this. Immediate bystander CPR. But that immediate bystander CPR bases on the person. If the person's seizing, people won't start doing CPR. If the person's still agonizingly breathing, people don't do CPR. So we need to really work on the fact that maybe by the time they are getting CPR by a bystander, that person may have already cardiac arrested for two or three minutes. So that's stuff we need to work on. The initial rhythm, anything but a systole, VTAC, VFib, PEA, we put all those on. Age less than 75. My mom's 82. She's very upset with that answer. And signs of life. Gasping still. Reaching up, obviously. Pupils that work. Any of that stuff is very good high-yield ECMO patient. No end-stage diseases. Again, end-stage liver, renal, liver, et cetera. And the arrest to cannulation time being less than 60 minutes. All of those are really patients that are great. And ECPR programs are basic programs in the hospital for in-hospital cardiac arrest or out-of-hospital cardiac arrest that are being brought into the ER. Historically, that's been very resource intensive, and still a 50% to 70% mortality. Why is that? That is because 73% of those patients who are dying after being put on ECMO, or after cardiac arrest, sorry, are dying from neurologic failure. And they're dying from neurologic failure because we're not doing steps one, two, and three fast enough. And we're not able to get to that, what I believe should be the next step, the fourth step, fast enough. So one of the ways that has been worked on this is Leonel Lammut in Paris did pre-hospital ECMO, hoping that this could cure. Their survival rates are around 30%, again, with the ELSO, the Extracorporeal Life Support Organization's data is, about 30% by getting to the people of Paris fast. That is the speed on all this. The faster you get to people, the faster you're going to be able to save their lives, the faster you're going to have improved neurologic outcomes. So Dr. Lammut has done this. There's been a couple other places around the world that have done small. Australia, Germany have done this. But the SAMU that Dr. Lammut has done is the ongoing one. And then the only other ongoing one, and you may ask, where is Albuquerque, New Mexico? It is over there. How did we get it? We are known as the Paris of the Southwest. It's a very frequent comment about us. And so again, we're proving it again. We have wine, interestingly enough. New Mexico was one of the leading wine producers in the country until Napa Valley. So kind of one of our little things. The monks brought wine to us. But outside of wine and pre-hospital ECMO, you would not think Paris and us have a lot in common. But we now do. We did our first ECMO case in the field back in September. Got some good publications on it. And we're able to really do that. And we're able to bring it. We've now done three total cases. So why have we been successful in getting PECMO, which is pre-hospital ECMO in Albuquerque, is because we have a really collaborative relationship with EMS. We have a critical care team that's willing to go out and do the cannulations. We don't have cardiac surgeons doing any of our cannulations at University Hospital, in hospital or out of hospital. We have critical care docs do all of our own cannulations. And the Department of Emergency Medicine also supplies the EMS physicians for this. So there's Albuquerque Fire Rescue, the Department of Emergency Medicine, EMS physicians, and then the critical care group who are all doing these cannulations. We have a very sophisticated EMS system in place. The lieutenants all carry ultrasounds and do echoes at the scene on all cardiac arrests to decide whether to continue. Our EMS physicians have pre-hospital transesophageal echoes. So they're dropping TE probes at the scene and doing echo there. The city bought 26 Lucas compression devices and put it on all of the Albuquerque Fire Rescue ambulances so we can now transport. Up until then, and I'll talk about this in a minute, people were just called on the scene. You call the medical director. The medical director pronounced them dead. And then lastly, what we needed to do was to come up with some economically creative solutions to the high cost and complexity of ECMO. One of the things we say frequently in New Mexico is one of our favorite states is Mississippi, because otherwise we'd be 50th in everything in the country. So it's like very good. New Mexico is a very poor state. We do not have a lot of resources. But what we do is have a lot of heart. So cardiac arrest in Albuquerque. If you cardiac arrested prior to 2017 at the little Mexican place across the street from the hospital, you either stayed there until you got returned to spontaneous circulation or you were pronounced dead. We didn't rush them into the hospital. EMS wasn't going to transport with physically doing CPR. They didn't have that. 2017, the city got all those Lucas compression devices. And we said, you know what? We're going to offer ECMO to any person in the city who can get to University Hospital within 35 minutes of the 911 call or of their arrest. The reason why we chose that is because we know it takes about 35 minutes to hit in the door. Using the reanimate kind of plan of getting people off the stretcher onto the table and then cannulating them, that probably takes around 15 to 25 minutes. And then we're still under the 60 minutes. So it gives us a little wiggle room. So who comes and who stays? You can see there, that is Albuquerque there. And there's a ring around the area that the paramedics have done. And this is like 5 o'clock at night, so high traffic time. And basically, what we say is if you're in that ring less than 35 minutes and they cardiac arrest, run to University Hospital. And we will put you on ECMO. Literally, I got a call just while I was texting there. And they just cannulated another person. So we're doing probably about 25 to 30 eCPRs a year at University of New Mexico in the hospital, in the emergency department, or people who arrest on the floor. If you're outside of that ring, we say, you know what? We're going to activate the PECMO team, okay? We're going to go drive to the scene and put you on. So we're self-selecting patients who would never have this opportunity to be put on ECMO because they were going to just be pronounced dead on the scene. We would not have ever run them into the hospital. Now we're able to offer that. If you look at that map, and if you've ever been to Albuquerque, interestingly enough, Balloon Fiesta Park is outside of that little area. And so we have different groups of people who can be in each one. So we're the only people in the state who do ECMO such as this. So really and truly, there's no other hospitals around. Albuquerque is a decently small city with only three major hospital systems. So but what about Orlando at 5 o'clock, right? So there's an app you can actually get where you can figure out how long it takes to get to a place. So this is to the convention center. I don't know where Eatonville is per se. You can see at the very top there. But if you're cardiac arrested in Eatonville and you were in New Mexico, you would not get transported, but we would go respond to there, okay? What about Baltimore where I did my fellowship, okay? If you are at the outskirts of Towson, you would not make it to University of New Mexico, or sorry, you would not make it to University of Maryland to get put on ECMO if you have a 35 minutes from time of arrest to getting there. So all of those different kind of times make you think to yourself, man, I don't really know if getting those people to the hospital and putting them on at an hour and 10 minutes is good because we already know that at 60 minutes, your neurologic failure is going to be much worse. So what did we do? We came up with this whole sample plan of how we're going to run pre-hospital ECMO. Let's say T minus 20, the patient cardiac arrest, okay? 9-1-1 gets called, bystander CPR starts. Minute later, the crew is dispatched. We taught all of the Albuquerque EM, sorry, 9-1-1 operators to recognize what a pre-hospital ECMO candidate would be, and we taught the dispatchers also to do that. They dispatched the ECMO team, the supervisor, all units en route. The ECMO team is, the ECMO ambulance, which I'll show you in a bit, is stationed at the nearest fire station to the hospital, which is only about four blocks away. They run to the bus stop. We jump in the ambulance at the bus stop, and we fly down. So we're using the on-call cardiothoracic intensivist for the day. The district crew gets on. The Albuquerque ambulance service is on scene. They're providing BLS, ACLS, hopefully getting that person resuscitated like that 33 to 35% that will happen if you have them on VTAC, VFIB, and otherwise they're just performing good CPR and going from there. At that point, the EMS physician arrives. They start to, they replay the indications for ECMO. They, if they get a chance, we've actually consented to people prior to putting them on. The families, the EMS provider did that. They drop a transesophageal echo probe or at least start managing everything. EMS is doing all their normal stuff, including glucose compression device. By the time then they move the patient to the curbside, they reverse load the person on the ambulance so that the person can go feet first into the ambulance. And the team, as we're driving to the scene, we start creating our ECMO supplies in the back of the ambulance while we're driving so that as soon as we do, we open the back doors and the patient comes in. There is our Albuquerque Fire Rescue. It was given to us, it was begifted to us, so entrusted to us to do this project. And the entire process, and I'll go over the cost, was $7,500 is our entire cost for the pre-hospital ECMO program. So you can see it says Advanced Cardiac Resuscitation Unit, ECMO 1. We basically, the cost was building that table in the back there. So, and putting the stickers on the ambulance, I guess. And so basically, we had a metal kind of OR table installed in the back of the ambulance. And then what we did is that ambulance stays really near the fire station, comes and picks us up, as I said. So we also stocked it with generous supplies donated by the University of New Mexico. We went into the OR, raided it, and stole a mess of wires and everything else we needed. And we told them after we did it, after we did our first one, they were like, where did you get the supplies? And we said, yeah, we got them from you guys, but they were okay with it. We ultrasound, we stuck the ultrasound on there with Velcro so we can move it up and down. We actually hang the probe from the ceiling with a bungee cord so we can pull down the cord, pull down the ultrasound probe sterilely. Do the ultrasound, let go, and it stays out of our way. Then you can do the other side. So you're moving along there. And we have all the cannulas in the back. In addition, we simplified the circuit. That is, you know, some people's simplified circuit, right? That's the rotaflow. There's some devices on there. That's not actually from us. We've really simplified our circuit down even more than that. But this is our back of the hospital, or the back of the ambulance circuit, right? We do the hand crank. We take the hand crank that is sold with every single ECMO device. That is what you have to use when your device breaks. And we just hand crank the person in, right? Now, there are no doctors of critical care calendars, but there are firefighter calendars. Those guys are strong. They hand crank the whole way in, right? So we get them on, and I'll show you a picture in a minute here of the guy hand cranking. But we basically put the ECMO circuits that's in there, the Quadrox is on the thing there. The hand crank is hooked to the rotaflow head. It's a big circle loop. It's all sterile set up. And then when we drive to the scene, we just put on the clamps at the top, and the clamp post-oxygenator. And then when we get on the scene and we go ahead and cannulate, we just activate it, and we start hand cranking. So let me go one more, there we go. There's the firefighter hand cranking right there. You can actually see the circuit cut and kind of still hanging from one of the bungee cords on the ceiling. And he hand cranks the whole way in. It's very simple. We have, we taught the paramedics to be our first assist for our ECMO cannulations. And we do it sitting there. You can see Dr. Detmer's knee is all covered with blood because when I cut the tubing, I actually didn't, I let the clamp off for a second, covered him. Sorry. Sorry, Todd, wherever you are. And so results so far this, since we started this, we've done three pre-hospital cannulations. The first two cannulations occurred at 58 minutes from cardiac arrest. So it met our guideline of being on less than 60 minutes. Remember, these people are by definition further away from the hospital. It's hard for us to do it. Our last one we did in 38 minutes because that person was actually in the ring, but they were on the third floor of their apartment building without a, without an elevator. So they, the fire department said this is going to take us a bit to extricate this person. They activate it. Dr. Detmer came from home. I came from the hospital. We met there. We hopped in the back, in our private cars. We hopped in the back of the ambulance and they put the person in. We had them on in 38 minutes. And the 38 minutes was actually eight minutes from the time they hit the back of the ambulance. So we cannulated them in eight minutes from the time we got there. All the patients were in advanced shock on hospital presentation with lactate greater than 10, except for that last one who actually had a lactate of four because we actually got to her pretty quickly. The patient had subsequent return of spontaneous circulation and lactate clearance while they were in their hospitalization. The first two patients had severe anoxic brain injuries leading to brain death. We tried to donate them, but there were reasons we couldn't donate. But the last patient was actually ended up having a GCS of five. We got her off ECMO and the family opted to not continue, not to do TRAIC or PEG. And so they withdrew. We did donation after cardiac death and got the kidneys donated. But we kind of as a proof of concept, we are now doing this and we're even talking about shrinking that little circle from 38 or 35 minutes because we got to a person who was physically close to the hospital so fast and we cannulated again in eight minutes from the moment they hit the door. That would never have happened in the ER. Okay, so our costs. We had no extra funding for this. There's no, you know, we're a limited resource state. The city donated an old ambulance to us for this project. They spent $7,500 getting it repainted with the stickers and putting that little table in the back that I designed in my garage. The hand crank is $5,000, but that hand crank actually comes with all the ECMO circuits. And so once we get to the hospital, we just do it. The rotaflow circuit's $1,400. When I had dinner with Leonel and he was like why are you not using a cardio help? A, because we don't have $120,000 to keep in the back of an ambulance. And we also don't want to have a $14,000 ECMO circuit that we're going to blow and put on a person who's, again, 25 to 30% survivability. So keeping it cheap, doing everything, $1,400 is what we use. We use the simple ECMO circuit. And when we, if it started to expire, we just put it into our normal ECMO circuit list and so we never expire circuits. We had ultrasound loaners from Phillips and Sonosite have been nice enough to loan us some ultrasounds. And we now have cerebral oximetry in the back of the ambulance that was donated by Massimo. Our cerebral oximetry, we only put people on who have cerebral oxes that are in the 30s to 40s. And then how do we make sure we're flowing good? Well, the blood turns, you know, dark to bright. And then we also use the compass pressure device, which is a small little thing for central line placement that we use as an art line. So we put a femoral art line in and we just publish the data. I was just presenting that up in Canada that the compass pressure device gives us a small, very accurate arterial line. And then we have a flow probe that, at least on these initial ones we're using. And our flows are four to six, depending on how much the firefighter cranks. Our mean arterial pressures are 50 to 60 moments after being on. We're not providing one liter of flow like CPR. We're applying five liters of flow if needed. When all of ECMO, or sorry, when everything started, we started with AMBU bags. We didn't start with a ventilator in the back of the ambulance. We didn't start with a Lucas compression device. We started with people doing CPR. Why do we need to start with the $40,000 Rotiflo or the $120,000 CardioHelp if you can just do it manually? There's no additional cost for personnel hours. So will this work? Hard to know. Time will tell. If the results from out of hospital cardiac arrest, like around 30%, start being replicated in PECMO, then we'll have a greater expanded zone of coverage. With this expanded zone of coverage, we'll be helping more people with our CrankMO kind of plan that we do. And so refractory cardiac arrest has a poor prognosis. Everybody knows that. We need to make that better. ECMO is one of the few interventions that doesn't actually move the needle significantly, three times the amount of survival normally. CPR is free, but traditional ECMO is expensive. So at UNM and the Albuquerque Fire Rescue, we've made pre-hospital ECMO or PECMO mean not only pre-hospital but also pragmatic. It's inexpensive, it's fast, and it's reproducible. So any, well actually we're going to do questions later, but that's the picture of ECMO one on scene. That's us cannulating in the back of there. There's that little tent that the fire department sets up in the back to cover. So, yeah. All right, on the tap the brakes side, we have Ravi Theorajan who is Chief of the Division of Pediatric Cardiac Critical Care at Boston Children's. He's a professor of pediatrics and has probably more ECMO experience than anybody. So I love putting people who are experts on the con side. Thanks, Julie, and thanks to the ACCM for inviting me to come present here. John, that was a fantastic talk. I mean, go on. Those are my conflicts of interest. I have two other things to say. One is that I'm a pediatric cardiac intensivist, so I take care of children with heart disease. And I really believe in ECMO. I can't do my job without it, so I'm biased, but I don't have a cat. Or I do have an oxygenator. It's in my office, and I use it to teach. I have a whole bunch of cannulas as well in my office. So I'm going to just really follow with John and take a slightly contrary position to doing pre-hospital ECLS and what the issues might be. I do believe that in the future we might be doing this, but perhaps we should think about how we want to structure this. So I'll go over outcomes for ECLS for cardiac arrest for in-hospital cardiac arrest, talk a little bit about what the challenges may be for out-of-hospital cardiac arrest, and say why we should tap the brakes. So ECLS for CPR, ECMO is really, just to get us all on the same page, ECMO provides you cardiorespiratory support when you get a patient on it. And when you use it during CPR, it provides you a flow during your low flow phase. So then you can actually make a diagnosis and treat the cost of cardiac arrest. The definition of ECLS or ECPR is ECLS initiated during ongoing chest compressions. So how does ECPR work? ECPR, like John said, provides you a cardiac output during your low flow phase. And it also perhaps provides you an opportunity to provide post-resuscitation therapies. So what is the miracle in ECPR? The miracle in ECPR is really providing good quality CPR, because the non-recognition of cardiac arrest or a long low flow phase is not going to be, your patient is not going to be saved by ECMO if all of those things are true. So quality CPR and reducing your low and low flow time are really important. Another aspect of ECMO that's really important is to get somebody safely on ECMO. So putting in the right cannula and providing the right support is really important in this population. So safe and effective ECMO support is really important. And most importantly, you have to have a treatable reason for cardiac arrest. So not all patients are going to benefit from ECPR. So unless these three things are true, then you're not going to have a successful outcome with ECPR. John showed this paper on looking at whether ECPR actually promotes survival in in-hospital cardiac arrest. And this came from the group in Taiwan. This is a single center report of two years, ECLS for patients with in-hospital cardiac arrest, adults, had a cardiac reason for cardiac arrest. And they went on ECPR if they had CPR for more than 10 minutes and didn't have return of circulation. And in this paper, they compared patients who got conventional cardiopulmonary resuscitation to patients who were rescued with ECMO. There were 130 patients, 13 patients in the conventional group and 59 in the ECPR group. And they showed that if you got ECMO to supplement your cardiopulmonary resuscitation, then survival with favorable neurological outcomes were better. But there were two issues with this paper. One is that it served a narrow group of patients. One, that most of these patients had cardiac disease. And the second is during the period of time that they were using ECPR, there were patients who were not resuscitated on ECMO. So something about those patients told providers not to put them on ECMO. And even though they used this analysis called propensity analysis, where you're really matching confounders into your two groups, there was something about these patients that told providers not to put them on ECMO. And that's not controlled in this study. So therefore, it's somewhat of a biased study. But it does provide some opportunity for us to think about ECMO as a resuscitative tool. These are outcomes for adults who get in-hospital cardiac arrest and ECPR. The outcomes are 25% to 30%. The majority of successes are patients with cardiac disease that have a reversible lesion, such as somebody with acute coronary syndrome, who gets a V-fibroarrest, gets on ECMO, goes to the cath lab, gets an intervention, and then can be weaned off ECMO. Patients who have asystole or PEA as their presenting signs often don't do well. Similarly, if you come to my field, it's about the same, about 40% to 50% survival in our population. And we, 75% of patients who get ECPR in pediatrics have heart disease. They are patients who have congenital heart disease who are recovering in intensive care units after congenital heart surgery and have a cardiac arrest in a monitored environment where we can actually provide good CPR prior to getting them on ECMO. These are recommendations from the 2015 guidelines from AHA guidelines for use of ECPR. And as you can see, it's pretty lukewarm. They don't recommend it for everything. Insufficient evidence for routine use. It only should be used in centers that are capable of rapid deployment of ECPR and in patients who have a reversible cardiac arrest. So all of these things are important when you carry it outside of the hospital and you have to make quick decisions getting patients on or choosing your patients for ECPR. And we all know that everybody is using it. This is growth of ECPR over time. This is data from the ELSA registry. There are about 170 or so centers around the world providing ECPR programs. And I'm sure it'll expand over time. So what about out-of-hospital cardiac arrest? There's two ways of doing it. One is your patient's arrested. Somebody's called. You send an ambulance. You get them on a mechanical compression device. You bring them back to the hospital and then cannulate them for ECMO and support them. And then provide your interventions to treat the cause of cardiac arrest. The other way is what John's doing here is what's called stay and play, where you send an ambulance that's equipped with ECPR equipment, ECMO equipment. And then you cannulate them on the field. The advantages of the first system is really you bring them back to a controlled environment where you can cannulate patients for ECMO. And ECMO cannulation is not without complications. Getting patients on ECMO has a lot of nuances. And I'm saying that from the pediatric world, where people have small vessels and it may be difficult to get them on ECMO. And you may save that time if you are able to do that out-of-hospital. But if you fail cannulating somebody out-of-hospital, then you're in real trouble. So advantages and disadvantages for both systems. And I was in Regensburg in 2015 at the Euro-Also meeting. And they had this excellent Audi car that, John, you should buy one of those so you can drive them really fast to get to your patient. And the car had all the equipment on the back of the car. And this, I presume, is the cannula or perhaps a yoga mat so you can put a patient on for cannulation. So yeah, I mean, everybody's interested in doing this. So just here is a look at some data. This is in-hospital cardiac arrest, in-hospital cannulation for out-of-hospital cardiac arrest. And really, most of this data comes from the group in Paris. They've just really pioneered this work. So this is 51 patients who had out-of-hospital cardiac arrest. Cardiac arrest had to be witnessed to be considered for ACLS. They had to have good CPR. And you have to get your patient into the hospital within 120 minutes to be a candidate for ECPR. The majority of patients in this series had ventricular fibrillation arrest. So they all had cardiac disease, so perhaps lower risk for poor outcomes in cardiac arrest. I want to point out that at least nine of these patients, even though they got cannulated in the ICU, failed ECMO cannulation. So this is a huge, this may be an issue for pre-ECLS cannulation. And two of 51 survived. And patients who survived actually got good cardiac output. And those are in the open, white circles. They had lower no-flow phase, which means that they had a witnessed arrest. They got CPR started early. And they had good entitled CO2 during CPR. So they got good CPR. Everything about ECPR is the CPR that you provide before getting patients on ECMO. And this is work on in-hospital ECPR. And these are some of the published reports. Anywhere from four to 30% survival. The more recent publication from the Minnesota group that John talked about is patients who had a V-fib arrest that was refractory out of hospital. They got put on a mechanical compression device, got to the cath lab, got cannulated, and then had a coronary intervention. And they're actually, with this practice, they've actually done pretty nicely with at least 40% survival in that group. So what about pre-hospital ECLS? The main reason to do pre-hospital ECLS is to reduce that low-flow time. So you're getting the ECMO to the patient, and thereby reducing the time that it takes for you to get patients on ECMO. And the first one of these reports was from Paris, and this is cannulating somebody who had a cardiac arrest at the Paris Marathon. So they brought this person with CPR into their ambulance, and they put them on the table. You can see somebody compressing, and then the surgeon's cannulating. So this is kind of the first report. This patient ended up dying, and a number of other reports, there was cannulation in the Louvre, there's cannulation in the Paris Metro. The outcomes are not as good. I mean, many of those patients died. And this is really their first report of a series of patients that they treated with pre-hospital ECLS. So between 2011 and 2014, they devised a system where they would take ECMO cannulation to the field and cannulate patients out there. They were also cannulating patients at the same time in hospital, and the way they decided that they would do field cannulation was that if they could not get a patient back into the hospital within 20 minutes, they would cannulate them on the field. The candidates were narrowly selected. Witnessed arrest, no flow less than five minutes. They excluded patients who had asystole or PEA, and they have to have had good CPR with entitled CO2 is greater than 10 during arrest. They cannulated patients if they had no return of circulation for 30 minutes, and towards the end of the study, they were cannulating patients at about 20 minutes. So there were 83 patients who had in-hospital ECLS, and 73 patients had pre-hospital ECLS. And even though many of those patients had died, in the case reports, in this series, they reported a 14% survival in this population. So really good. I mean, people are able to do this. There's no doubt about that, but is it the right thing? So here's my pitch for tapping the brakes. So I am all for saving somebody's life, so I would do pre-hospital ECLS, but does it really improve out-of-hospital cardiac arrest survival outcomes? And I used data from that Paris paper. They had 15,680 out-of-hospital cardiac arrests, and about 1% of that population were eligible for ECPR, and half of those patients had pre-hospital ECPR. So 0.5% of out-of-hospital patients would have been patients who qualified for pre-hospital ECPR, and 10 of the 73 survived. So your overall increase in out-of-hospital cardiac arrests would have been increased by 0.1%. So should you really do this, you need better systems and more development before you can actually consider this as a viable therapy. The problem with ECPR, is it for all or for some? And that's been a challenge. It's a real challenge in pediatrics. It's certainly a challenge, I would say, in adults as well. Are you going to consider somebody in asystole, somebody with respiratory failure who had an arrest? So what about those patients drowning, somebody who's hypothermic? So all of those things are huge issues. We just don't have good guidance on those. Quality of CPR is really crucial. If you don't provide good quality CPR, your patient's not going to do well. And then what is failed CPR? Do we have a definition for failed CPR? Is it 10 minutes without return of circulation? It's all over the place. There's just no standardized way of approaching patients who have arrested, and imagine, you're actually doing this on the field, where you just don't have any other help, and it's all about you. You have to make these decisions. And then what if you fail to achieve cannilations in the field? Would you just say, I'm sorry, and walk away? Or would you get this patient back to the hospital? If you were cannilating somebody in an ICU, you may consider opening a chest and cannilating somebody through the chest. If you're out in the field, then that's just not an option for you. So what would you do for that? And then is it cost effective? It almost seems like we may have to redesign our cities, because if you don't have access to patients, if you can't drive your ambulance fast enough to reach your patients, then this may not be a good option. So, and your eCPR team, I mean, John, you're really very fortunate that you were able to do this, but you really have to have a skilled cannilator for this. And can we teach our EMS personnel to do cannilation? I certainly think that's possible, but it's gonna take a lot of training. You need your equipment, and eCPR is a real rare event, and it's a very complex event where you're managing CPR as well as ECMO cannilation, and it's complex. So, and it's rare, and if it's a rare event and it's complex, you lose your skills, so you have to have ways of teaching people to maintain their skills. And then we don't have any idea of the long-term and functional outcomes, and this is an area of lack of data in ECMO itself. So, those are all major issues, and I am sure in the next several years that we will learn how to do this and perhaps do this well. So, I said I was gonna tap the brakes, but I work in a field where I really need ECMO and eCPR to save my population. So, I might say I would tap my brakes lightly, and we'll probably need to learn a lot more on this before we say yes or no to this therapy. So, thanks very much. Thank you. in hospitals that don't do ECMO, that need ECLS, and that's an unsolved problem. I work with hydrochloric acid. We're having a hard time kind of negotiating with our Yeah. You know, ECMO is certainly useful for the right indications. It is, I would say, extraordinary therapy at the moment, because there's just really no standardized ways of using it. I think it's certainly, in large quaternary ICUs, I think ECMO, using ECMO is beneficial in many patients. In my ICU, I can't imagine running a complex cardiac unit with lots of heart surgery going on without ECMO. I do think that letting a patient rest before you cannulate is just not a good idea. And there are many patients that offer you the opportunity of intervening and cannulating up front. So I think we should develop systems. I am very much against regionalizing ECMO services. And I think most ICUs should have the capability of getting a patient on ECMO and stabilizing them. Even if you're not going to care for that patient for the entire course, you can certainly have another center take that patient. So I would be for developing ECMO programs that are proximal to patients and provide an opportunity of ECMO support before the patient rests. I would be very much in favor of that. So we have a sister small hospital that's like 25 miles from the university. And what we're doing there is I just purchased a hand crank for that hospital. And so we are actually going to try to roll out... So, basically, our helicopter stays in the airport, which is near us, we have PALS, position access, line call, and so we get a call, we run to the roof, we have everything prepackaged up, actually, on a board, spine board, and then they just put that in the back of the helicopter, and then we just take off and go. So, our plan is to have the little rural hospital be able to cannulate people with the critical care doctors who are there, and then we will be there in 30 minutes, and they'll only have to hand crank for a very short period of time to do this. Again, to me, the Henry Ford model of this thing is like, get the hand crank in as many places as you can, and then do it. So, I'm not an ethicist, but I've cared for, as many of you have, people who are waiting for organs, and I've cared for patients who have died who have been able to donate. And that process is pretty incredible for all parties involved. I'm wondering if you would feel it, if in time, when we see the outcomes that we're looking for, if they don't pan out to improve mortality, but improve the ability for organ donation, if that would be ethically appropriate, worth the investment, or how that might be accepted as far as your perspectives at this time. So I would say that if I put somebody on ECMO, I'm hoping that that patient would survive. I don't think of that patient as an organ donor. And that's a very challenging area, because some patients do turn up to have brain death. In fact, the Paris paper, 90% of those patients who died were brain dead. So they would have been organ donors. But I think it's really challenging to think of ECPR to create an organ donor. I think that's ethically challenging for me. I'm doing this to save somebody's life. And if I fail, then perhaps we may have to rethink how we approach that. We have a very aggressive donation program, and we actually, we've grown our... or it's not as eCPR, but I think you'd like, and maybe the audience knows exactly how they're doing it. But they've asked us to partake, and if you're sure, tell me what you want, and I'll do it. Hi, Sam Tisherman of the University of Maryland. I've got a question about doing eCPR in the field without any kind of heater in your circuit. What kind of temperature do you achieve when the patient, I mean, therapeutic hypothermia is probably a good thing, but too low could be bad. So what kind of temperature do you get when the patient gets to the hospital? Sam. Oh, hey. I don't think any of our patients were profoundly cold. They were probably in the mid-30s, like 33, 34, if they were cold at all. But I mean, in California, right? It's not around in North Carolina. Not in Chicago. Thank you to all of our speakers. I really appreciate it, and thank you everybody for coming.

burnout

wellness

pre-hospital ECMO

learning healthcare system

positive work environments

ECMO in cardiac arrest

early recognition

emergency medical services

high-quality CPR

survival rates

challenges

skilled cannulators

ECMO programs