24 Hours… of ECMO
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Part IV: Past Midnight
Saturday: 1:00 am
STS and the Paperwork Deluge
So at something like 1:00 am, it’s do or die time. The patient is fine, but as an ECMO coordinator, I typically like to stay awake and support the ECMO nurses that are watching the patient.
It’s the perfusion scan thing. Always doing it. I have become a sentinel and don’t even know it when I am doing it.
It’s in all of us I think. Perfusionists that is- constantly scanning, taking mental notes with invisible ink that we don’t even know we are writing. I personally like that trait. The ability to absorb and think when engaged in something else.
So now is the opportunity to get caught up on STS data harvest collection. A ream of paperwork waiting to be collated into X’s & O’s so that our institution can stand up and be measured by the Society (of everything- name it- and we’re on it) of Thoracic Surgeons.
The goal is to get a good report card. The premise for that report card relies pretty much on the following:
(But that’s on the Adult side- The Pediatric STS equation is far more complex, and a different animal)
- Don’t die within 30 days of your operation date
- If you do die past 30 Days- make sure it’s not in the same admission
- PreOp Meds: Beta Blocker for all Coronaries: Satins for lipids: ASA: for antiplatelets
- Low M & M
- Low LOS
- Low ICU LOS
- Early Extubation
- No Reintubation
- No “Bring backs”
- No Readmission within 30 days
- Less than 24 Hour Vent times
- No new onset of Dialysis
- Less blood product is better
- Fast transition times (Intubation-Cut-Close-Out of OR)
- Postop Meds: See PreOp Meds…
STS & What the numbers don’t show
The goal is three Stars.
Never-mind the fact that most rating systems work on a 5 or 10 scale program. A 3 star rating from STS means you are truly excellent at what you do- for whatever the category may be. Top 5 % or better…
The caveat on the other hand, is that if you forget your audience, and loosely throw around the “concept” that we are a “3 Star Program”… Well that doesn’t translate well if the rest of the human race is working on a Base 10 system.
My opinion? Stars are relative to the players.
So it’s back to work to visit with Mona.
An amazingly good nurse, mother, and a great people person. She is a machine with a conscience. She cares, and she cares a lot.
If your child is under her care, well you are lucky, because there is only one of her, and so many children.
I had the pleasure of getting a phone call two years ago while I was in the OR, from Mona. It was pretty cut and dry.
“We are decannulated”
Most of the time a message like that implies that a patient was successfully weaned from bypass/ECMO and it was “all good”.
The second half of reading into that message was that if we had weaned off- well, I would have had to been been there to do the weaning…
It took a second for that to correlate, and I was in the ICU in 37 seconds or so.
So yes we were indeed de-cannulated (carotid side), and doing compressions to stabilize blood pressure, and while the arterial line was compromised, we had the venous line access that allowed for volume delivery back to the patient as the surgeon was busy re-cannulating.
The circuit had not de-primed thanks to Mona- and shunting volume to the patient via caval access was no problem at all.
Once a patient is seperated from ECMO (unintentionally or with the intent of maintaining cannula purchase in order to reestablish cardiopulmonary support), the attending perfusionist must recognize that there are two distinctly seperated (by geography) patient environments in terms of heparinization. The patient has lost acces to a heparin feed from the ECC- and the pump circuit as well is still getting a heparin dose delivery from the heparin syringe pumps. It is essential that both sides of the heparin equation here are monitored as separate environments to assure the ability to reengage bypass.
The event was rare, and no board question prepares you for it. You just do what you do, and recognize that the staff around you are well prepped and ready to respond.
Mona held her ground and was amazing in terms of her calmness and 100% response.
So it was good to see her. And we always come back to that moment (that get’s further away in time) of when the perfusion/ECMO side of the team made a big difference.
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