All right, so let's begin. So in other words, I wouldn't be qualified for ECMO, I just want you to know, I'm just not good plasma or protoplasma or whatever. All right, so you heard about a lot of these great studies, such as the RAS actually was really involved with this, actually helped write the letter to the editor for these guys when they had it published. And so I know a lot of the data and what you just saw here before, it's cool. And they're even saying, well, it's so good to get it done early, let's go into the streets and get it done. And that's sort of what's happening. But keep in mind here is that the pages in this study, you know, were like somewhere in the ballpark, mean age of 59 and 83% were men, by the way. So one of the things, if it's so good, then let's take it to the streets. And these guys did it. Many of you from France and elsewhere in Europe know that they took it to the streets. And so I've actually been out there helping them, the classic thing, you know, with them in the, they always have this thing where they were in the museum, you know, live. And so that's why she was smiling, because they got them back, okay. But they did also say, we got to do it on scene, because there's difficulties in traffic. And then actually things got worse after they started this program. The mayor decided to cut down those tunnels, right, where you travel through, where Princess Di got killed. And because it was just whatever, and it caused more traffic problems than ever had before. So safety, security, quality, et cetera. So that's the thing. So bring it on, McDonald, what, Michael McDonald, the doobies, right, taking it to the streets. So not only there, but other places around the country. Just before the COVID epidemic, the people in Newton were taking hand-cranked versions of ECMO out in the streets in New Mexico and various other places around the world. Many of you have done it. Some of the studies, though, have really been kind of good. Like the folks in Paris, I actually stole these slides directly from Lionel Lemieux and Pierre Carly, and they showed that your no-flow time was, you know, was done better if you did pre-hospital, you know, instruction and application of this thing. Here's the but. Whenever you hear me, you always look for me saying, here's the but, okay? And there have been some studies that are going out there, and there are either trends or not quite there, and they don't show statistical significance, but there have been some trends in those regions. But they just didn't quite seem to make it, and they questioned more and more, should we bring it to the streets? And so I think instead, most of us have come to the conclusion that what we want to do is actually get people together and give protocols and find out and create resuscitation centers, for example, that they're ready to do the ECMO when you hit the door. They've done it in San Diego, they've done it in Los Angeles, and many other places. But who are the candidates for out-of-hospital cardiac arrest, you know, that's interesting. Persons with persistently recurring VF, perhaps, right, preferably witness cases in some protocols, even those with bystander CPR. And then, would you add anything else to that, or is that pretty much it, the candidates? Yeah. Okay, so we got concurrence up here. So cath center and ECMO, are they ready to go 24-7, practitioners, maybe do we have to have practitioners, and I think you should have practitioners like in Paris, people who do it all the time and are facile at it, and can get it done out there in the streets early, if you're gonna take it to the streets or anywhere, even to the emergency department or whatever. So, here's the deal, what ages should we take, are the patients 18-65, 70, 75? Turns out, I can get ECMO in Los Angeles, but I can't get it in San Diego, just want you to know, so, okay, so I have that conflict of interest. But is the transport time recommended less than 30 minutes, clearly the earlier the better, so there's all that. So here's the problem. The problem is bystander witness VF and no ROSC, just taking that alone, not even saying CPR or anything else like that, or age, is that it's about less than 5% in most US systems, even the ones that are performing so well. So I went to the guy who's running our Florida Resuscitation Center program, and I said, how are we doing statewide, and he said, and this is his text, I just copied it and pasted it in here this morning, in our data from last year, only 2% of patients would qualify as witness, shockable, under 70, and no ROSC, okay? So, which means ongoing ventricular fibrillation and so on. So that's a problem, and most cardiac arrests all together are non-shockable, and if you ask, I was just at a talk with Dr. Yiannopoulos, and he asked him, or even what we just heard from our previous speaker, is that really non-shockables were probably not somebody we would go after. Now, he asked the guys in Paris, they go, well, if they go down right in front of us, maybe we'll do it then, and they're asystolic or brady-asystolic, but for the most part, they are excluded, and by the way, as am I, as a result, because of my age, et cetera. There's obviously the issue of expense, resources, talent, and skills is what you have to be thinking about if you're gonna implement this, okay? So, is there a better neuroprotective bridge to ECMO, is what I'm gonna suggest, and what's really nice, because he brought this up, there's something that could be an expanded use for ECMO candidates if we were able to do this, and many of you saw that yesterday. Here's the spoiler alert, you know, that I'd already given the presentation on this yesterday about using the act of compression, decompression, but hey, Raul, you know when I took this, by the way? I took it in Paris in 1999, just to let you know that's how long this has been going on, but you're pulling blood out of the, you know, you're creating the vacuum, so you're pulling blood out of the brain and back into the chest, and you allow more circulation up there instead of them colliding up there and causing these things that really limit your blood flow across the brain. So, the other thing that we've done, as he mentioned, was, if I can get this thing to go, I'm not sure why I can't, maybe I gotta get outside the picture, is that adding that ITD in there will really improve your thing, and by the way, this is classic, you got Gazboury right here, you got your cerebral perfusion pressure, goes down to, you know, that, and we're starting CPR, and over a period of time, it goes down, et cetera, and then whereas the ACD-ITD keeps it expanded, and we know that it gives you 50% improve it neural intact outcome in the studies that were done, you know, some 10 years ago and published in The Lancet. All right, so, there are new things that are being applied. The problem with the Lucas device, as far as I'm concerned, I know the people in the audience will be upset with me, but, is that it just doesn't pull up enough, I think, as the other thing does, so it gives you some decompression, but not, you know, as good as we would like it to be, and in fact, okay, under those circumstances. Bottom line is that we would suggest that you've got to not only have this on board, but perhaps we all, most of our systems that have been using this have used the actual pump itself, the manual pump first, then they might switch over, especially for transport purposes or whatever, to the other, and then this gradual elevation of the head, and make sure, if you didn't hear my talk, you apply those other two things first, you got to prime the pump. If you raise the head up, not good, you can't get blood uphill, and it could be detrimental, let alone the fact that it's not, you know, that it won't help you, but if you get the pump primed with those other two things in red, and then you get them going, and you get blood uphill, and you gradually elevate them, then you're having these great outcomes that are being published, and you can look this up right now, of course, that was just, you know, published this weekend, and the editorial is fascinating, I love, the guy who reviewed it, I hope he was one of our reviewers, because I had great reviewers, Critical Care has great reviewers, and so anyways, Chris Colwell, he is, I think he is the Vice Chair of Emergency Medicine at the University of California, San Francisco, worth looking at. All right, so we got really good outcomes, those of you who were there yesterday showed that if we got there in 11 minutes, which is the median time of application, it was pretty impressive, you know, you had these dramatic outcomes, and even if you got there within a quarter hour of the 911 call, or 999, or 112, wherever you are, they really had terrific outcomes. But let's show you something else, good neurological outcomes, if you just overall look at all this versus the current data from the CARES database, you are getting these tremendous improvements in outcomes, and here's what we're talking about, it's really pronounced in bystander witness, out of hospital cardiac arrest presenting with those ventricular dysrhythmias, where you're getting, you know, 35% versus the 27% for these, what do they call them, utstein, whatever, criteria, whatever. So I knew that, and then look at this, I'm going to present this tomorrow, but I thought I'd give it a little bonus shot here, is that even in unwitnessed cardiac arrest presenting with asystole, which we most would all say futile, you know, not worth trying here, we were getting, it was 1.5%, but more importantly, is that when you got it done within 11 minutes, it was approaching 3%, and you say, well, 3% neurologically, 3%, that's low, but when you're talking about 400 cases a day, it can start adding up, not only in the United States, but worldwide and all that. And this is what we've been seeing, people who are coming back now, CPC1s only is what we're basically seeing, and you're affecting not only the people, but their family members and all that. And by the way, talk about head up stuff, because you were one of the people that have written about that early on, Raul, and he, I always say that it's the human condition to be up, like, why aren't you watching this like this? It would get better blood flow to your head. It's the human condition to drain blood out of your head, so that's the thing. By the way, you sort of heard me talk neuroprotective, I don't know if that's an appropriate term to call this, but where we got it from was this guy right here, he's one of our patients, and he's a 40-year-old guy who, what was interesting about him is that he actually is a guy who's a paramedic who harvests, well, he doesn't harvest the organs, but he goes, collects them, and brings them in for transplant, so he knows about brain dead people and all that. So when he found out he had been down for about 35, 40 minutes and came back perfectly normal, he said, how'd they do that? And he told them, and he goes, well, that's like neuroprotective. So we like the term, so we had that. It's more cerebral protective from my point of view, and there's Kerry Bacista, by the way, who's the first author of the paper, that's his system that resuscitated him. One last thing is head position after we got him back, right? One of the things that's interesting is that you're just in the laboratory, you know, looking at things, and we're trying new things, so we were looking at this one three-block symmetry tool to see how it worked, how it worked. Turns out when you're in a supine position in the animal, and it's in humans, too, they're using this in New Mexico, you get a 65%. There's a little bit more VITAS admixture, and then it goes down to 22% or 25% or whatever or less. And then when you're in CPR, with CPR, you get it up to about 40%, and then as we gradually get the head up and all that, we get you back up to 65%. You get back to normal blood flows. And by the way, the humans were seeing normal internal CO2s when we did this application, so that's a good sign that we're getting good flow. So anyways, I'm in the laboratory, and we used this thing, and I said, that's interesting, okay. And then as we resuscitated him, we did a shock, and it comes up to 75%. So what about that's about? Is it some kind of auto-regulation thing? But we said, okay, we're just observing it. Then as he's lowering the animal down to de-instrument it, I notice it's going back down to 65%, which is kind of where we started in the beginning when we started the whole adventure. And I go, humor me, go back up again, and he did, and we can see it's totally reproducible. So we were then, with that observation, we did a paper and showed that you're improving supra-oxymetry and supra-perfusion pressure by putting the head up after we resuscitate. And lo and behold, since we're talking about ECMO today, head and thorax elevation prevents the rise of injury and pressure during extracorporeal resuscitation in a swine. So I would love to have you guys out there looking at this, right, and studying it, and showing us, because you have instrumented patients and so on, and you can probably give us the answer. Daddy can talk. Yep. Look who knows so much, huh? Well, it just so happens that your friend here is only mostly dead. There's a big difference between mostly dead and all dead. Please open his mouth. So anyways, in conclusion, everyone, I think we're going to get back people where we go, and I look at the head up thing we just talked about as a bridge to ECMO. And we may be able to expand the use more beyond the people with ventricular fibrillation and so on, I hope. And on the road to the 2030s, by the way, I want to say I'm Paul Pepe, and I approve this message with all the stuff going on in our country here. And thank you very much, everybody. Okay. Thank you.

ECMO

cardiac arrest

resuscitation centers

protocol development

manual devices