When the COVID-19 pandemic first hit in early 2020, the burden fell on health care teams to prepare and determine the best clinical protocols to combat a disease that none of us had never seen before. We immediately learned just how rapidly COVID-19 could ravage both a person’s respiratory system and a region’s hastily prepared heath care systems in hard-hit areas such as New York, Seattle and others. As a cardiothoracic transplant surgeon, I sensed that my colleagues and I would play critical roles in the COVID-19 battle. However, it would require a novel combination of connection, communication, innovation and hope.
Connection
As physicians facing an unknown, potentially devastating disease, we all raced against time because we knew that the information needed to care for COVID-19 patients had to flow faster than the pace of published articles in medical journals. Colleagues began sharing information immediately by email, text and calls.
Connections were renewed as we urgently reached out to trusted colleagues around the world, from Professors Pascal LePrince and Alain Combes in Paris, to a former partner, I-wen Wang, MD, from Memorial Healthcare System in Hollywood, Florida, who connected with his colleagues in China to gather and disseminate their observations and protocols so we could learn from their early experience.
We received incredibly helpful, but sobering, information.
Embedded in the information about treating this disease, were reports of the deaths of health care providers as well as the need for robust supplies of protective equipment for all team members.
Early studies demonstrated that 6 to 10% of those infected with this novel coronavirus, or SARS-CoV-2, developed a more severe form of the disease and would require intensive care unit (ICU) admission due to acute hypoxemic respiratory failure. Many of these patients would go on to require invasive mechanical ventilation due to diffuse lung injury and acute respiratory distress syndrome (ARDS), and some would suffer eventual cardiopulmonary collapse. As cardiothoracic surgeons, we use extracorporeal membrane oxygenation (ECMO) during ARDS in non-COVID-19 patients and began exploring if, as a last therapy, ECMO could be used in appropriate COVID-19 patients with refractory respiratory failure to provide time for resolution of the pulmonary injury, giving them a chance at survival.
During this time, physicians at ECMO centers from around the country connected. We asked questions like, What were you seeing? What treatments were working? Which patients responded best?
In applying lessons from old diseases, we rapidly brainstormed to develop best approaches to this new foe.
One group, comprised of 17 leading ECMO centers throughout the country, formed a consortium and began working together to assemble information and results. This group included cardiothoracic and vascular surgeons from AdventHealth in Orlando, New York University in New York City, Massachusetts General Hospital in Boston, Baylor University in Dallas, Northwestern University in Chicago, Duke University in Durham, Albert Einstein College of Medicine in the Bronx, Rush University Medical Center in Chicago, University of Texas Health Science Center in Houston, Ascension/St. Vincent’s Medical Center in Indianapolis, Westchester Medical Center in Valhalla, New York, and North Shore University Hospital in Manhasset, New York.
This consortium of partners, now called the COVID-19 ECMO Working Group, recently published the first of our collective findings in The Journal of Thoracic and Cardiovascular Surgery and in the National Center for Biotechnology Information Resource List.
Communication
At AdventHealth, we carefully examined our capacity to provide ECMO to COVID-19 patients at our three ECMO units* located on our campuses in Orlando, Daytona Beach and Tavares. We developed standard criteria for its use and determined how we could expand our available number of ICU beds if needed.
In addition to our internal preparations and participation in the national consortium, we also tapped into all our existing professional relationships with ECMO centers throughout Florida and the Southeast. Within Florida, several of us helped to establish a secure online network where ECMO physicians could share information and conversations about our experiences, current capacity and availability to help each other. These relationships, communication channels and referral lines have proven critical in managing the ECMO needs of patients in our state as the disease has surged in different communities at different times.
Innovation
In the beginning, we were unsure which COVID-19 patients would benefit from ECMO and therefore were extremely cautious in selecting patients for this therapy.
We began with providing only veno-venous (VV) ECMO support for those patients experiencing severe respiratory failure. Later, because some patients with COVID-19 develop severe cardiac failure, including myocarditis, massive pulmonary embolism, stress cardiomyopathy, arrhythmias, and acute coronary syndrome, we began providing veno-arterial ECMO when appropriate, and developed a sense of when to switch and when to combine these modes.
Our team continued to innovate and evolve, learning from each case and from our colleagues’ experience around the country so that we could pare our therapy to the most efficient and effective approach. We ascertained which patients did better and why, as well as how to best support them. This included incorporating proning and oscillating vents, as well as keeping a critical eye to which medications were most effective. It also involved maintaining proper patient nutrition and anticoagulation when possible.
Most importantly, we learned that our COVID-19 patients may require months of support, but a significant number of them did eventually get better. In fact, AdventHealth’s survival rate for COVID-19 patients on ECMO stands at 65% and has remained above the published national average of 55%. I believe this is due in large part to our integrated, multidisciplinary team, which includes dedicated pharmacists who help us to continually incorporate the latest clinical findings and therapies into our treatment plans. We also observed early on that our obese patients did as well or better than other patients, contrary to the accepted guidelines and plan to publish those findings soon.
As we gained experience, we adjusted protocols and developed new care standards. Our team contributed to and currently follows the COVID-19 ECMO guidelines established by the Extracorporeal Life Support Organization and based on available evidence, existing best practice guidelines, ethical principles and expert opinion. We will share our “Obesity in COVID ECMO” data and findings at an upcoming ELSO meeting for consideration in the next iteration of their guidelines.
Recently, ELSO awarded AdventHealth Orlando “The ELSO Award for Excellence in Life Support” and named us a Designated Platinum Level Center of Excellence, their highest level of achievement, in recognition of our exceptional results in delivering ECMO. I believe the extraordinary efforts of our team in meeting the demands of treating the COVID patients from our region pushed us to a new level of performance.
While we are certainly grateful for the recognition of our teams’ achievement, there is nothing that means more personally to our ECMO team than the people we have helped save, and the hope and compassion we gave to those we could not.
Hope
Over the span of the pandemic, our team has cared for over one hundred ECMO patients. Sadly, not every patient recovers, but our team has noticed the ones who exhibit gratitude, positive attitude and a drive to get back to their normal life usually have a better chance of recovery.
A couple of extraordinary patients stand out – Piero and Terry. These two patients jumped at the opportunity to work with our team, they didn’t say no to physical therapy, and they worked hard to do their part to go home – they had the will to live.
In July 2020, Piero Saenz, 29, initially suffered only minor symptoms due to his COVID-19 diagnosis. However, after several weeks at home, he found himself struggling to breathe and came to our emergency department at AdventHealth East Orlando. Diagnosed with ARDS, Piero transferred to our Advanced Cardiac Surgical Unit for ECMO treatment at AdventHealth Orlando.
During the nearly six months Piero was an inpatient with us, we talked about how he grew up, his family and his goals in life.
As a physician, understanding each patient, not only their physiology, but who they are as a person, to provide meaningful inspiration that resonates with the patient is an integral piece of the puzzle so they know they can get back to the life they had pre-COVID-19.
Piero spent over 110 days on ECMO before his discharge to recover at home, where he continues his journey toward healing.
He is such a kind, motivated soul and he quickly became a part of our ECMO family. Our entire team wanted to help this determined young man and we’ve all been inspired by his incredible heart and tenacity. Watch Piero’s story of survival by WFTV here.
Terry Greear, 42, maintained an active, healthy lifestyle, but in January 2021, found himself in an area emergency room a few days after testing positive for COVID-19. Initially admitted to the ICU, Terry was soon transferred to AdventHealth Orlando due to his need for ECMO and the possibility of a double lung transplant. All in all, “Coach Beard” – a nickname he earned years ago by one of his kindergarteners who had trouble pronouncing his last name – spent 72 days in the hospital battling the virus, 27 of which were on ECMO at AdventHealth Orlando.
When we made the decision to put Terry on ECMO, I called his wife to give her the update and I could hear not just the fear, but the love in her voice. She went from despair, thinking her life partner would die, to hope that perhaps ECMO might save him. During these dark times, hope and prayer are all you have.
During his hospitalization, the father of two sons lost 50 pounds, his lungs collapsed twice, and his iconic beard had to be shaved off. The real lifesaver for Terry became the ECMO machine and the team responsible for administering his clinical care; without this combination, he wouldn’t be here today.
The road post-COVID-19 has been long for this Cypress Springs Elementary School physical education teacher and East River High School junior varsity boys’ soccer coach. Because of the virus, he’s had to re-learn how to do basic tasks, like dressing, washing dishes, walking and even talking.
While COVID-19 may have temporarily silenced Terry, his voice and message are stronger than ever: get vaccinated.
The vaccine has proven effective in preventing death and hospitalization; vaccines will give stressed, overworked and exhausted frontline health care workers the much-deserved break they need during this global crisis.
Watch Terry’s fight for life and hear his message to for anyone who hasn’t gotten the vaccine here.
Thankfully, both Piero and Terry were able to come off ECMO and start rehabilitating their bodies. However, healing the lungs is not an easy feat. Aside from time, prayer and physical therapy, there aren’t any tools to heal the lungs.
We’ve noticed the patients that can get up and move around are the ones who get better, but that takes a certain motivation to live, in addition to help from our entire team.
As physicians, we are all truly in this together. When patients like Piero and Terry are dying from COVID-19 and are at the absolute end of what they can tolerate, our ECMO team believes in “the possible” and offers hope. While it’s a village that no one ever wants to rely on, I feel fortunate to be a part of it.
*AdventHealth’s ECMO unit, one of the largest in the country, is made possible by community support through the AdventHealth Foundation Central Florida.