EDECMO Podcast

 

ED ECMO Podcast — Episode Synopsis

This episode of ED ECMO, hosted by Zack Shinar, explores the emotional, neurological, and psychiatric outcomes of ECPR and ECMO survivors — going beyond survival statistics to examine what it means for patients to truly live after ECMO.

Segment 1: ECPR Training & the Delphi Analysis (with Shan Modi) Shan Modi, critical care physician and associate ECMO medical director at Allegheny General Hospital, discusses a multinational Delphi analysis surveying 50–55 ECPR experts across 20–25 countries to establish standardized learning objectives for ECPR cannulators. He and Zack then pivot to Shan’s commentary on an EXCEL registry study that prospectively examined quality of life in ECMO patients — revealing that 70% of ECMO patients either develop a new disability or die from comorbidities, underscoring the gap between binary survival and meaningful recovery.

Segment 2: The Emotional Landscape of Survivors Zack and Shan discuss recurring emotional patterns in ECPR survivors:

Fear of sleeping after arrest, worried it could happen again

Survivor’s remorse — patients feeling disconnected from celebration because they “just went to sleep and woke up”

Anxiety and depression months after discharge

The ethical concern of advertising patients as “survivors” when they may prefer to simply return to normal life

Segment 3: Post-ICU Care & Caregiver Burden Shan advocates for dedicated post-ICU clinics for ECMO patients (modeled on Dr. Brad Butcher’s work at Pittsburgh), offering multidisciplinary follow-up with PT, OT, social work, and psychiatry. He also shares early findings from his ongoing caregiver interview study (24 caregiver-patient dyads), revealing that caregivers face acute-phase overwhelm and subacute-phase stress, financial strain, and guilt over struggling to care for themselves while caring for their loved one.

Segment 4: Neurological & Psychiatric Outcomes (with Dr. Sung Min Cho) Dr. Sung Min Cho, neurointensivist at Johns Hopkins and co-founder of the Whitman-Cho ECMO research lab, discusses:

Acute Brain Injury (ABI) rates far exceeding ELSO registry reports — meta-analysis showing 17% in VA ECMO, 10% in VV, and 20–50% in ECPR

Neuropsychiatric symptoms (insomnia, depression, anxiety) persisting in 30–40% of survivors at 6–12 months

Lack of pulsatility in VA ECMO causing small vessel brain injury, analogous to known LVAD complications

Rapid CO2 correction during ECMO initiation linked to hemorrhagic and ischemic stroke, confirmed in a swine model showing basal ganglia injury

The Safe MRI ECMO Study — a multi-center trial using bedside low-field MRI (0.064 Tesla) on patients while on ECMO, finding a striking 44% ABI rate, far higher than any prior study, revealing subclinical injuries invisible on standard CT scans (cir-150-1955.pdf, Clinical Use of Bedside Portable Ultra-Low-Field Brain Magnetic Resonance Imaging in Patients on Extracorporeal Membrane Oxygenation: Results From the Multicenter SAFE MRI ECMO Study – PubMed)

Segment 5: VV vs. VA Differences & Take-homes VV ECMO patients showed higher neurocognitive impairment, likely due to longer hospitalization, heavier sedation, and prolonged paralysis. Key recommendations for ECMO programs:

Optimize initiation parameters (sweep gas, CO2 correction rate, pulsatility monitoring)

Minimize sedation and benzodiazepine duration

Establish long-term follow-up and support groups for survivors

Recognize that neurocognitive sequelae are common — patients should know they are not alone

The episode closes with both guests reflecting on how ECMO uniquely brings together diverse specialties — ED, surgery, critical care, engineering — unified around saving the sickest patients.

What happens when emergency medicine, cardiac surgery, critical care, ECMO, and human factors collide in the highest-stakes environment imaginable? Mark Ramzy takes us inside the CTICU to explore the art of resuscitation—and why knowing when to move fast, when to slow down, and how to work as a team may matter as much as the technology itself..

 

In this episode of ED ECMO, Zack Shinar sits down with Mark Ramzy, an emergency medicine–trained cardiothoracic intensivist, to explore what resuscitation looks like when the patient is already surrounded by ECMO, LVADs, invasive hemodynamic monitoring, recent sternotomy, and a highly specialized multidisciplinary team.

Mark shares practical lessons from the CTICU, including how post-cardiac-surgery arrest algorithms differ from traditional ED resuscitation, when to shock rather than immediately perform chest compressions, how to recognize impending deterioration, and why knowing when to “speed up” and when to “slow down” can make all the difference. He discusses open-chest resuscitation, internal cardiac massage, VA ECMO as an exit strategy, and his experience with double sequential defibrillation.

The conversation then moves beyond procedures into the human factors of high-stakes medicine. Mark describes working alongside cardiothoracic surgeons, interventional cardiologists, intensivists, nurses, respiratory therapists, and emergency physicians—and argues that successful ECPR depends less on territorial boundaries and more on recognizing what each member of the team brings to the table.

Finally, Mark offers a cautionary perspective on the rapid expansion of ECMO and ECPR. As these technologies become increasingly accessible, he emphasizes the importance of quality control, mentorship, humility, and developing strong relationships across specialties. His overarching message is simple: medicine is a team sport, and the best resuscitation teams know not only what they can do, but when to listen, when to slow down, and when to let someone else lead.

EDECMO 105: Becoming an ECMO Coordinator?

In this episode, hosts Zack Shinar and Jon Marinaro are joined by Jonathan Goldstone, ECMO Coordinator at Sharp Memorial Hospital, and Rachel Wallace, ECMO Coordinator at the University of Minnesota ECMO Program, to explore one of the least understood but most important roles in an ECMO program—the ECMO coordinator.

The discussion begins with recent advances in their own programs, including dramatic reductions in ECPR cannulation times at Sharp through improved teamwork, standardized equipment, and streamlined workflows. This sets the stage for a broader conversation about how successful ECMO programs are built and sustained.

Rachel provides a detailed overview of the ECMO coordinator’s responsibilities, including onboarding and training ECMO specialists, competency assessment, simulation education, quality assurance, ELSO registry management, physician education, equipment evaluation, and research support. Jonathan emphasizes that while coordinator responsibilities vary between institutions, the central mission is always the same: ensuring there are no weak links in the ECMO system that could compromise patient care.

The panel clarifies the often-confusing distinctions between perfusionists, ECMO specialists, ECMO coordinators, and ECMO managers, highlighting that ECMO specialists may come from nursing, respiratory therapy, perfusion, or advanced practice backgrounds, while coordinators oversee education, quality, systems improvement, and program development.

The conversation explores how hospitals should think about hiring an ECMO coordinator, arguing that programs should invest in leadership early—even before case volumes become large—to build the infrastructure necessary for safe and sustainable growth. The guests also discuss how coordinators influence equipment purchasing, mobile ECMO development, process optimization, billing, and multidisciplinary collaboration.

A recurring theme throughout the episode is that ECMO is fundamentally a team sport. The guests stress that efficient ECPR depends less on individual expertise and more on standardized processes, constant communication, simulation, and shared mental models among physicians, nurses, respiratory therapists, perfusionists, and ECMO specialists.

Finally, the discussion turns to professional development for new coordinators. The guests encourage listeners to leverage the ECMO community through conferences, podcasts, ELSO resources, WhatsApp discussion groups, and mentorship from experienced programs. They conclude by emphasizing that ECMO practice continues to evolve rapidly, requiring coordinators and physicians alike to remain curious, adaptable, collaborative, and committed to continuous improvement.

Key takeaways:

The ECMO coordinator is the operational leader who integrates education, quality improvement, data management, research, equipment, and systems engineering into a cohesive ECMO program.

Successful ECMO programs depend on standardized processes, simulation, and multidisciplinary teamwork rather than individual heroics.

Every hospital must develop an ECMO program tailored to its own personnel, patient population, and resources rather than simply copying another institution’s model.

Continuous learning, collaboration, and engagement with the broader ECMO community are essential for building and sustaining high-performing ECMO programs.

Jon Marinaro interviews Dr. Eric Nadler along with Dr. Gary Schwartz our guest for the second episode in a row

Key Takeaways

Cancer is increasingly becoming a chronic, manageable disease.

ECMO may be appropriate in carefully selected oncology patients.

Close collaboration between oncologists and ECMO teams is essential.

Modern cancer therapies can work rapidly enough that ECMO may meaningfully change outcomes.

Awareness and education gaps exist on both sides:

intensivists may underestimate modern oncology,

oncologists may underestimate ECMO capabilities.

Eric Nadler, M.D., MPP, is board certified in medical oncology. He serves as a medical director of US Oncology Health Outcomes. He remains active in US Oncology Network and Texas Oncology research committees in lung cancer, head and neck cancer, and sarcoma. Dr. Nadler’s passions are oncology research and oncology education.

Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak –   Episode 103

Key Points: ECMO in HIV/AIDS Patients

1. HIV Is No Longer a Strong Contraindication to ECMO

Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO.

With modern antiretroviral therapy (ART), outcomes have dramatically improved.

Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy.

Therefore, HIV alone should not exclude patients from ECMO candidacy.

2. Immune Reconstitution Makes Recovery Possible

ART can rapidly suppress viral load and restore immune function.

Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time.

This means even severely immunocompromised patients may recover if given time and support.

ECMO can act as a bridge to immune recovery.

3. ECMO Functions as a “Pause Button”

ECMO stabilizes respiratory or cardiac failure while clinicians:

Treat infections

Start ART

Manage complications

This buys time for reversible disease processes to recover.

4. Major Cause of Respiratory Failure: Pneumocystis Pneumonia

Common features in HIV patients requiring ECMO:

Pneumocystis jirovecii pneumonia (PJP)

Severe respiratory failure

Cystic lung destruction

Frequent bronchopleural fistulas and pneumothorax

Ventilation can worsen these conditions.

Thus ECMO is used to:

Reduce ventilator pressure

Prevent further lung damage

Allow lung healing.

5. Ventilator Strategy: Minimize Positive Pressure

Typical strategy:

Rapid ECMO initiation if ventilation causes lung injury

Attempt early extubation

If needed:

tracheostomy

minimal ventilator settings

Example “rest settings” described:

Driving pressure ≈ 10

PEEP ≈ 10 (often reduced further)

FiO₂ ≈ 50%

Goal: avoid further lung trauma.

6. ECMO Candidate Selection

Primary question:

Is the disease reversible?

If yes → ECMO should be considered.

Factors supporting ECMO:

Young patient

Treatable infection

Potential immune recovery

Possible relative contraindications:

Severe fungal infection

Multiple uncontrolled opportunistic infections

Extreme cachexia or severe systemic deterioration.

7. Early ART Should Be Started

Modern approach:

Start antiretroviral therapy during acute illness

Do not delay until after ICU discharge

Benefits:

Rapid viral suppression

Faster immune recovery

Risk:

Immune Reconstitution Inflammatory Syndrome (IRIS)

Temporary worsening of infection due to immune rebound.

8. Circuit and Infection Complications

Important ECMO considerations in HIV patients:

Increased risk of circuit thrombosis

Possible fungemia

If fungemia occurs:

circuit replacement

possible re-cannulation

These complications require careful monitoring.

9. Cannulation Strategy

Example high-volume center approach:

Bilateral femoral VV ECMO cannulation

Fast

Reliable flow

Allows later neck access if needed

Used especially during high-volume periods (e.g., COVID).

10. Outcomes and Indication Expansion

ECMO indications are evolving:

Older age

Longer ventilator times

HIV/AIDS

Cancer patients

All are examples of “indication creep” as experience grows.

The key principle remains:

ECMO should be used if there is a realistic chance of recovery.

11. Resource and Program Considerations

Decision-making must consider:

Resource availability

Program experience

Institutional risk tolerance

High-volume ECMO centers can often accept higher-risk patients.

12. Broader Lesson

Medical contraindications often change with new technology and therapies.

Example given:

HIV was once a contraindication for kidney transplantation

Now it is accepted due to improved treatment.

The same evolution may be happening with ECMO indications.