SMCMA Physician

Cardiac Arrest Protocol Could Save Hundreds of Lives

Extracorporeal Membrane Oxygenation or ECMO is an established therapy that provides both cardiac and pulmonary support for patients. In short, the ECMO equipment takes over the job of pumping and oxygenating a patient’s blood, allowing the heart and lungs to rest while a planned cardiac procedure, such as a stent or valve replacement, is performed.  

This type of heart-lung by-pass machine is not new, but one pioneering physician has begun using ECMO therapy sooner and with a broader patient profile, in the hopes of saving even more lives. “What we’re able to do now is get people onto ECMO so quickly that we can start using it for emergency response to cardiac arrests,” said Joe Walsh, MD, an Interventional Cardiologist with Palo Alto Medical Foundation.  

Sutter’s Mills-Peninsula Medical Center (MPMC) launched its ECMO program in 2017 and has treated approximately 25 adults a year with ECMO over the past two years. Dr. Walsh is director of the ECMO Program, and with his leadership and that of San Mateo County EMS medical director Dr. Greg Gilbert, MPMC became the first hospital in the state to launch a new emergency response protocol known as eCPR in March 2019. This protocol is characterized by the early use of ECMO for patients who have a sudden cardiac arrest — a population who have not historically benefited from this therapy.

The eCPR (or extracorporeal CPR) protocol relies on two key changes to standard practice: 

1. Patients are rushed to the hospital sooner rather than after a half-hour of attempting to restore spontaneous circulation through CPR and medication in the field; and 
2. Once at the hospital, patients are put on ECMO as soon as possible, and remain on it until doctors have had the opportunity to assess and repair the underlying catastrophic heart condition.

The eCPR protocol has been proven effective in a 2016 study by at the major Minneapolis-St. Paul area hospitals.  Although a small study, the results were dramatic. Historically, following the standard protocol for sudden cardiac arrest in the community, survival to hospital discharge with minimal cognitive impact (cerebral performance categories 1 or 2) was 8.2 percent for that group of hospitals. With the new eCPR and ECMO protocol, survival to hospital discharge with minimal cognitive impact jumped to 50 percent.

“For the past 60 years, we have been unsuccessful in improving survival from sudden cardiac arrest,” Dr. Gilbert said. “With this protocol, we have the potential to go from 15 percent of patients surviving to 45 percent – and that’s survival to discharge with no neurologic deficiencies.”

The potential benefit was clear to Dr. Walsh and colleagues, but the road to making the necessary changes — in the pre-hospital setting — was less so. 

Until recently, it’s been next to impossible to perform uninterrupted CPR safely while in transit. “Our protocol has been to perform CPR at the scene and start transport only if we can stabilize the patient,” said John Kammeyer, Fire Chief for San Mateo Central Fire. Unfortunately, many patients never stabilize and die before they even reach a hospital.

The widespread use of a mechanical device that delivers continuous CPR is set to change that. The device, known as LUCAS (Lund University Cardiac Arrest System), delivers the same 2-inch chest compressions that a human hand would during traditional CPR, but the machine makes the process “hands free.” This means that emergency medical technicians (EMTs) can start their drive to the hospital sooner. A LUCAS device is carried on every San Mateo Fire rig that serves the county, and two of the LUCAS devices now in the field were donated by Mills-Peninsula Medical Center in support of their use in the eCPR protocol.

“All of the medicines I can provide on the scene, all of the CPR that we do, it isn’t going to change what’s going on with the patient’s heart,” said Annie Flick, RN, a paramedic with San Mateo Central Fire. “So the key is to identify these patients early, touch base with Dr. Walsh, get them activated in the system, and just get them to the hospital as quickly as possible.”

The eCPR protocol not only prioritizes getting patients to the hospital over attempting to stabilize them in the field, it also includes a system to fast-track care once the patient arrives at the hospital. A pre-hospital alert system and checklist ensures that the patient is a candidate for the ECMO therapy and serves to notify the ECMO team, the cardiac cath lab and others that a case is incoming. 

“We can now buy people more time, which will save lives,” Dr. Walsh said. “The LUCAS device buys time by helping to get patients to the hospital faster, and Mills-Peninsula Medical Center can also buy time by initiating advanced life support sooner. The application of these available technologies for a new population is an innovation I’m proud to offer to the residents of San Mateo County.”

Emma Dugas is the Communications Coordinator Bay Area for Sutter Health