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Staffing
An ECMO service is entirely dependent on its people. The team is organized to provide a continuous service, 24 h a day. Table 2.1 provides an example of a list of the key members of the team. This will vary from centre to centre, depending on local and national organizational factors.
All members of the team require specialist knowledge in managing the ECMO patient, and a robust teaching programme should be established. The volume of activity of a centre should be sufficient to allow availability of the required resources for training. Staff training should be mandatory. Regular refreshers should be provided and competencies regularly assessed. Table 2.2 lists the topics that the in-house training programme should cover. The ELSO provides regularly updated guidelines and resources for the training and continuous education of the ECMO specialist.
| Types of ECMO |
| Risk and potential benefits of ECMO |
| Indication and contraindication for ECMO |
| Pathophysiology of the patient on ECMO |
| ECMO equipment (including circuits) |
| Gas exchange on ECMO |
| ECMO emergencies |
| Inserting ECMO: Why? When? How? |
| Liberation from ECMO: Why? When? How? |
| Coagulation management while on ECMO |
| The post-ECMO patient: immediate and long term |
| Complications of ECMO |
| Cost of ECMO |
| Transfer of the patient on ECMO |
The team of educators must be allocated time and resources to attend state-of-the-art conferences. Educators can then ensure their local programme is up to date. Training should include regular water drills, during which a primed circuit is used without being connected to a patient. This allows familiarization with the equipment and identification of potential issues. Staff are trained to recognize and manage specific ECMO emergencies, and then do it again and again.
A list of competencies expected from each role for clinicians involved in the management of the patient on ECMO is useful. These can be developed at the local or national level, and the ELSO provides examples and ready-to-use lists.
Multidisciplinary meetings should be scheduled on a regular basis and newly acquired knowledge and experience shared to ensure the whole team continues to learn and evolve.
Doctors
Doctors looking after ECMO patients will require multiple skills. The ideal ECMOlogist would be a surgeon, intensivist, chest physician and anaesthesiologist combined. This person should have acquired the skills of many different specialities. As this is rather unusual, a good ECMOlogist will be a ‘connexist’, i.e. someone who can recognize his/her own limitations and call on others’ expertise. The closest to this ideal are intensive care doctors as they are usually working in this manner.
The starting point for any doctor wishing to learn ECMO is a thorough understanding of the ECMO circuit itself (see Chapter 3). The second key clinical skill to acquire is how to select the right patients, i.e. patients requiring support while recovering from a reversible insult or eligible for another type of long-term support (see Chapter 5).
The ECMO community has a great tradition of supporting each other. These days, multiple courses are available to teach the basics of ECMO. Clinicians involved in ECMO are always willing to help each other.
Adult intensive care skills are central to the safe delivery of ECMO, and all the basics of intensive care management should be adhered to.
ECMO is a complete system of care, not just a bolt-on accessory.
Junior doctors should be involved in all aspects of the care of ECMO patients. The first skill they will need to acquire is to recognize their limitations and when to call for help.
ECMO specialist
The ECMO specialist has a key role. They are immediately available in the clinical area and are the first line between ECMO and the patient. They require advanced skills to ensure no harm comes to the patient. They are the first line in managing the patient and circuit emergencies and, in addition to excellent technical skills, should have effective communication skills and the ability to work in stressful situations.
The ECMO specialist will be skilled in the care of patients on ECMO, and should have a strong intensive care background.
The ECMO specialist must achieve competency through completing the necessary training and assessment. Practical skill sessions concentrate on circuit surveillance, troubleshooting and emergency procedures. Emergency procedures such as air embolus removal are practised repeatedly to ensure competency.
The ECMO specialist can undertake other roles, such as ensuring appropriate anticoagulation, and titrating ECMO flow and gas to ensure adequate levels of cardiac and/or respiratory support.
ECMO specialists can be nurses who have undergone additional training, or can come from other specialities, such as perfusion or medical backgrounds.
All nurses caring for the ECMO patient must have basic skills specific to both the intensive care unit (ICU) and the ECMO patient. They must be able to act immediately in a case of a catastrophic failure of the ECMO circuit. An ECMO circuit must never be left in the hands of a practitioner who is not qualified to look after it.
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