Boston EMS personnel participate in an ECPR simulation at the STRATUS Center.

When someone’s heart suddenly stops beating, also known as cardiac arrest, every second counts.  Invented in the 1960s, conventional CPR techniques using chest compressions have been the default treatment for cardiac arrest for nearly 60 years. While CPR can be a lifesaving intervention when performed by early bystanders, studies have found its overall success rate is still low. One of the newest therapies seeking to improve cardiac arrest survival combines early CPR with another technique: extracorporeal membrane oxygenation (ECMO). This new method of cardiac arrest care is called extracorporeal cardiopulmonary resuscitation (ECPR).

Brigham physicians recently teamed up with Boston first responders to help the city’s paramedics and emergency medical technicians (EMTs) enhance their approach to treating cardiac arrest by implementing a new ECPR protocol. The protocol is now in use at the Brigham.

ECPR can be used to combat some of CPR’s shortcomings. While traditional CPR utilizes artificial breaths and external chest compressions to circulate the body’s blood to vital organs, the overall efficacy is still not optimal. ECPR, on the other hand, can do the work of oxygenating and circulating the blood using an advanced machine. To perform ECPR, the patient’s blood is passed through an ECMO device, which reoxygenates the patient’s blood before pumping it back into their body.

“If you don’t get your pulse back after three rounds of chest compressions and shocking, or defibrillating, the likelihood of survival is much lower, so that’s where we can introduce putting certain patients on ECMO,” said Raghu Seethala, MD, medical director of the Brigham’s ECMO Service and section chief of Critical Care in the Division of Thoracic Surgery. “ECPR is not replacing CPR, but rather it’s an added, newer therapy for a certain subgroup of patients who have not gotten their pulse back after initial interventions.”

However, ECPR can be challenging to implement. The procedure is highly time-sensitive and requires seamless and efficient coordination from all parties involved, which is why Boston Emergency Medical Services (EMS), the Neil and Elise Wallace STRATUS Center for Medical Simulation, the Department of Emergency Medicine and the Division of Thoracic and Cardiac Surgery all came together on April 8 to simulate an ECPR resuscitation from start to finish.

Far right, foreground: ECMO team members Arzoo Patel, PA-C, and Rasha Al-Nadabi, MD, simulate a resuscitation as colleagues observe.

The effort builds on the Brigham’s continued work to expand ECMO access. In 2020, the hospital launched its ECMO Transport Program — one of the first of its kind in Boston — to provide the lifesaving treatment to critically ill patients during transport from hospitals throughout New England to the Brigham.

The simulation gave physicians and first responders the opportunity to evaluate the quality and efficiency of their ECPR care without any risk to a live patient. The simulation started with a high-fidelity manikin in the STRATUS Center experiencing a mock cardiac arrest. Boston EMS was activated and responded to the scene to initiate both CPR and the new ECPR protocol. Boston EMS then transported the manikin to the Emergency Department (ED) at the Brigham, where the ED and ECMO teams were awaiting their arrival to start the life-saving steps of ECPR.

“The goal of it was not so much to focus on the medicine,” said Andrew Eyre, MD, MS, medical director for the STRATUS Center. “It wasn’t to say, ‘This wasn’t the right dose of medication’ or ‘Your CPR wasn’t good enough.’ It was to test the systems. Does everyone know where the equipment is? Do all the pagers work? Can people get down in time?”

The simulation identified several opportunities to improve the ECPR program including equipment storage and labeling, improvements in the activation of the ECPR response via the paging system and methods to improve the workflow of the teams involved. However, one of the most important takeaways from the simulation was how to improve the complex communication that is necessary between a large, interdisciplinary team when faced with a critically ill patient.

“In medicine we are very good at training in our silos,” said Paul Jansson, MD, MS, lead for quality and safety programs at the STRATUS Center. “The physicians may train with other physicians, but this program is particularly valuable because it brings together people who don’t normally work together for high-stakes scenarios that really need to be right the first time.”

Because the simulation included Boston EMS, the team was able make sure that every person involved in caring for a patient suffering from cardiac arrest followed a common protocol. Organizers of the April 8 simulation say the event marked a big step toward wider adoption of ECPR and enhanced cardiac arrest care.

“ECPR is a big team effort,” Seethala said. “In these scenarios, this is where high-fidelity simulation is the best because we were able to simulate almost exactly what a real patient would be like from start to finish. It was extremely important to have Boston EMS involved in this exercise because they’re the first part of the process.”