An advanced form of life support known as extracorporeal membrane oxygenation, or ECMO, is seeing increased use at Methodist Hospital in San Antonio, driven in part by the COVID-19 pandemic and a mobile ECMO program that can reach patients hundreds of miles away.
Methodist Healthcare System’s flagship hospital in the South Texas Medical Center is home to the only platinum-designated ECMO program in San Antonio, the highest certification awarded by the Extracorporeal Life Support Organization, or ELSO.
The hospital’s ECMO program has ballooned since the first machine arrived in 2013.
Usage surged during the COVID-19 pandemic as doctors treated infected patients whose lungs continued to fail despite ventilation.
That growth has continued to accelerate. Methodist Hospital is on pace to perform around 300 ECMOs this year, surpassing the technology’s use even at the height of the pandemic.
The hospital’s 24/7 mobile ECMO team, which can deploy within 15 minutes, is also expected to break its own record this year. The team has traveled as far as Las Cruces, New Mexico; Houston; the Lower Rio Grande Valley; and into Mexico to stabilize critically ill patients before transporting them to San Antonio.
And in March, the hospital launched specially equipped EMS vehicles designed to transfer ECMO patients between Methodist hospitals.
“As we continue to grow our capability, we just find that there’s more patients that can be helped [with ECMO],” said Dr. Jeffrey DellaVolpe, medical director of ECMO at Methodist Hospital.
How ECMO works
ECMO is one of the most advanced forms of life support, reserved for patients experiencing life-threatening heart or lung failure. The machine works by pumping blood out of the body, removing carbon dioxide and adding oxygen, then circulating it back into the patient, functioning as an artificial lung or heart.
The technology has been around for decades, saving its first life in 1971. But ECMO fell out of favor for years following disappointing early studies, in part because of the risks involved and uncertainty about which patients were most likely to benefit.
Its use began to rebound during the 2009 Swine Flu pandemic, along with improvements to the machines themselves and a growing body of evidence that found better outcomes in certain patients.
ECMO does not treat disease. Instead, it serves as a bridge stabilizing patients long enough for their lungs or heart to recover, or until they can receive a transplant or have a life-saving device implanted. For ECMO to work, the underlying condition has to be reversible, DellaVolpe said.
Doctors often consider ECMO when conventional treatment has failed in cases of severe respiratory failure or cardiogenic shock, which can happen during heart attacks, acute respiratory distress syndrome (ARDS), sepsis, pneumonia, blood clots and infections such as influenza and COVID-19.
Mortality rates for ECMO patients are generally high, largely reflecting that the technology is reserved for those in the most critical condition.
In a 2016 survival analysis of 4,227 Taiwanese patients, three out of four ECMO-treated adults died within one year. Outcomes varied widely depending on the condition being treated, the patient’s age and how long they required ECMO support. In a 10-year look at one ECMO center in Austria, overall three-month mortality was 41%.
“You want to make sure that if you’re taking the risks of putting someone on ECMO, they are having some failure of conventional management. But there are some disease processes that are so responsive to ECMO and so poorly responsive to any other therapies that we’re a little bit more quick to be able to offer it,” DellaVolpe said, pointing to life-threatening asthma attacks as an example.
ECMO in San Antonio
Methodist Hospital received its platinum designation from ELSO last year, making it the only platinum-certified program in the city.
CHRISTUS Children’s Hospital, Brooke Army Medical Center, University Hospital and Methodist Children’s Hospital also have ECMO capabilities. Hospitals in Houston and Dallas are also home to platinum-level programs, according to a map on ELSO’s website.
Prior to the pandemic, Methodist Hospital performed about 10 to 15 ECMO cases per year. During the COVID-19 years, that number rose sharply, reaching as high as 190 annually. The hospital is now on pace to perform around 300 ECMO cases this year.
DellaVolpe attributed the growth to the health system’s expanding footprint in South Texas, as well as growth in lung and heart transplant programs and cardiovascular care, trends that have increased demand for critical care.
That growth prompted the hospital to roll out new, specially equipped EMS vehicles in March that can transport ECMO patients between Methodist hospitals.
“All of those things combined — the growth of ancillary programs, the growth in the complexity of the hospital, and just the growth of our catchment areas — we’ve continued to grow and better serve the area that’s around us,” DellaVolpe said.
Mobile ECMO
Methodist’s mobile ECMO program began around nine years ago, allowing the hospital to bring ECMO directly to critically ill patients before attempting transport.
“The vast majority of patients, if they need ECMO, they’re probably not stable enough to be able to transfer into an ECMO center,” DellaVolpe said. “You have to put them on a transport vent, you have to take them out of the ICU, you have to load them in an ambulance or a plane. They have to be able to survive the transport. And for a lot of these patients whose hearts or lungs are failing, they may not be able to tolerate that.”
The hospital has about 33 ECMO pumps, about half of which are transport-capable.
The mobile team has expanded its reach over time, traveling across Texas and beyond. Patients are placed on ECMO at the bedside before being transferred to Methodist Hospital by ground ambulance, helicopter or jet.
The hospital maintains an around-the-clock mobile ECMO team that can be deployed in as little as 15 minutes.
Though there are often closer ECMO programs than Methodist Hospital, ECMO transports are resource-intensive and require resources many hospitals can’t spare for hours at a time, DellaVolpe said.
“It means being able to dedicate a physician, a perfusionist, a nurse, a transport team that can be gone for several hours to be able to go and get these patients,” he said. “Some programs, even some very large programs, say that’s not going to be what they’re going to offer. This is a big priority for us.”
