RNs running ECMO on adult patients - page 2
by pbear | 16,073 Views | 20 Comments
I had my first patient on ECMO this past week. A very intense experience but one that was made much easier because a perfusionist was at the bedside 24/7. I knew next to nothing about ECMO, other than what is was being used for.... Read More
- 0Jul 12, '12 by IHeartDukeCTICUI'm all about taking care of ECMO patients as an RN cause they are super sick and very challenging and require every ounce of critical thinking. That said, I would not want to be responsible for running the pump without going through the ECMO specialization course and getting tons of clinical experience with it, prior to running it alone. ECMO is one of those high risk/low volume devices, so you may not get as much experience with it in comparison to other devices like a balloon or vad. Having witnessed an ECMO circuit clot off and 2 perfusionists and a fellow frantically having to crash them onto the spare ECMO pump, as well as witnessing an ECMO decanulation which involved a hot bloody mess in which they re-cannulated, I wouldn't feel confident in doing the same things without an in depth training and clinical exp. Even if there were "on-call" perfusionists for emergencies, they may or may not get there in time in those types of situations so the responsibility would rest on you.
- 2Jul 12, '12 by ghillbert, MSN, NP GuideQuote from IDoNotGiveOutWith all due respect, it IS just like a VAD. They are both pretty mechanical circulatory support devices. I have worked with ECMO, IABP, VAD etc for 15 years +. VAD and ECMO both require the same knowledge of technology mixed with advanced anatomy and physiology. The degree and depth of knowledge required is obviously variable depending on your role and responsibilities. As both a biomedical engineer, CCRN, and now nurse practitioner, I absolutely maintain that ECMO is like any other piece of equipment. I do not mean to minimize the criticality of the therapy, but with adequate training (and yours sounds great), there's no reason the right RNs can't learn to manage ECMO circuits.I am an ECMO specialist but my day job is being an ICU nurse, and I can tell you it is not even close. Let's be honest, when we have a balloon pump or VAD, mostly we just write down numbers, we had to learn a few assessments/checks to do and a few precautions to follow, and it is extremely rare for anything to go wrong, and if it does we just do what minimal, simple interventions we know how to do, panic, and call perfusion. Not necessarily in that order But you're still doing typical ICU nursing, it's another machine in your patient's room and it is critical, but it doesn't significantly change the general job duties. Being an ECMO specialist is an entirely different ball of wax. ECMO specialists require a few weeks of full-time additional training to become certified, it is not like getting VAD or ballon pump certified. When the ECMO managing physician isn't present, the specialist is the leader of the team caring for that patient, and you are responsible for anything that happens. You have to make complex decisions regarding management of anticoagulation, clotting, bleeding, and hemodynamics/oxygenation (the physiology and management is very different than any other ICU patient). You have three circuit pressures you are monitoring, three separate blood gasses to interpret to determine how to adjust your sweep gas and pump flow, but must also take into account pt. BP, native CO, gtts, patient lung function, vent settings, volume status, cardiopulmonary anatomy (e.g. in our congenital heart babies or neonates with shunts), type of support (VA, VV, VAV), where they are cannulated, patient assessment, circuit assessment, etc. etc. And even just the routine necessary things you do often require accessing the circuit, which is extremely high risk, as in if you turn one stop cock the wrong way you could cause a massive catastrophe. And if there is some kind of circuit catastrophe, until the ECMO doc, perfusionist, and other ECMO specialists get there to help, you alone are responsible for fixing it, while the rest of the ICU team that is coding the patient is screaming at you "how much longer?" Don't get me wrong, there are times on very stable patients where it's mainly just watching blood pump in a circle and jotting down numbers. That's why they say being an ECMO specialist is 90% boredom and 10% sheer terror.
To answer the OP's question, ECMO is scary and hard and it is not for everyone. It requires a certain level of passion, you have to be a little obsessive to soak in all the knowledge needed, and you have to be the type of person who is willing to be the only person in the room who knows anything about this crazy machine that is usually the only thing keeping the patient alive. I disagree with your statement that only perfusionists should staff ECMO pumps. With proper classroom, lab and clinical training experienced ICU nurses/RTs are qualified and capable to do the job, and do at most ECMO centers. It is not like you'll (usually) be doing full CBP with circ arrest. But that doesn't mean it's simple enough for a "ten minute crash course." That is completely insane. Our initial training is 80 hours, plus 4 hour comps every 3 months. Also, if they aren't offering you a nice pay differential, they are robbing you. When we sit a pump we get paid the same rate perfusionists get paid to run bypass in the OR. ECMO requires you dedicate much of your personal life to learning this, being on-call, and shouldering huge responsibility and high stress levels, and being exposed to some of the most emotionally demanding situations possible, above and beyond the demands of being an ICU nurse. The job absolutely deserves additional compensation.
Sorry for the long post and I know this is two years old. But when I saw one person say that only perfusionists should run ECMO and then another say it's just like a VAD, I couldn't help myself.
- 0Jul 17, '12 by juan de la cruz, MSN, RN, NP GuideRN's do run ECLS at our institution with the Mechanical Circulatory Support team on call for higher level troubleshooting. The intensity of the workload (more frequent assessments, labs) make it justifiable to have 2 nurses assigned to the patient each shift.
- 1Jan 5 by BigCliffCCRNI agree with this comment. ICU is ICU is ICU. although miracles do happen and most people respond well to the treatments we provide, not everyone makes it. Plus, its more fun and interesting to deal with more machines, have more under your belt and develop more skills and use your brain more, there is only so much you can learn about turning someone and cleaning them, day after day. How about learning new things and making yourself indispensable, thats how I feel. Just an opinion.
- 0Jan 5 by armyicurnQuote from BigCliffCCRNWell said brother! We are is the same wavelength !I agree with this comment. ICU is ICU is ICU. although miracles do happen and most people respond well to the treatments we provide, not everyone makes it. Plus, its more fun and interesting to deal with more machines, have more under your belt and develop more skills and use your brain more, there is only so much you can learn about turning someone and cleaning them, day after day. How about learning new things and making yourself indispensable, thats how I feel. Just an opinion.
- 0Jan 6 by Chad CollinsLook at it this way every new skill you add to your tool bag will net you more money at you next job. As nurses we always have to look forward for increase in pay and to do that we have to become more valuable to future employers. I work a cardiac PCU floor and I recently got trained and certified for Aquaphoresis ( kind of mini dialysis for CHF patients) I don't get any more money now but when i move out of state end of the year my next employer will take all skills into consideration. Good luck
- 1Aug 17 by nowplayingjcJust sharing an ECMO article I wrote. Cheers!
I am an ECMO nurse. I work with a machine that helps patients who have 80% chance of dying. In a critical care environment, they are considered as one of our most precious patients, if not the most. I got trained for this, and I must admit that it took me a while before I gained the confidence in calling myself an ECMO nurse.
I'm an ECMO nurse. It's winter, so it's the busiest time of the year for us. I'm exhausted, but I love my job, so I need to suck it up. Let me just tell you more about what I do. This is not a ***** rant!
I am an ECMO nurse. You tell me that I only sit on my bum and do ACT every 2 hours, but you really don't have any clue, do you? I don't value doing the ACT itself, but the numbers that I get from it. I adjust the heparin infusion because I always want to get the balance between my circuit not clotting and the patient not bleeding his brains out. It is always a fine line, but we thread it carefully because we know the consequence of a very deranged ACT.
I am an ECMO nurse. I come with my flash light and I look for fibrins all the time. I search for newly formed strands and make sure that all existing ones are not getting any bigger. If the clot is in post oxygenator line, my anxiety level is high, for I know that if it dislodges, it goes directly to the patient, and the result won't be very good especially if it's a VA circuit.
I am an ECMO nurse. I send blood tests every 6 hours, and I correct whatever I can. If the hematocrit is low, I give my patient a unit or two of RBC. If the platelet is low, I make sure that I adjust the heparin infusion before giving a bag of platelets. All these things affect the smooth run of my circuit, and the worst thing that could happen is the machine just going to a full stop.
I am an ECMO nurse. I deal with plasma hemoglobin all the time. When it's high, I check for other signs of hemolysis like the urine turning pink. I don't want to be that random ECMO nurse who gets a high plasma hb after it has been normal for many days. It's either there's a big clot that suddenly appeared or I just forgot to remove the smart site before taking the sample. Either way, I still do my post oxygenator blood gas just to make sure that the oxygenator is still working well.
I am an ECMO nurse. Though I treat my circuit like a fragile baby, my priority will always be the patient. I work with you to keep this patient alive and to make him better. His hemodynamics, his sedation, and everything you do to the patient will affect my circuit in one way or another. So please tell me if you'll do something. I'm not trying to be difficult: the patient is alive because of this machine, so I just want our patient to stay alive.
I am an ECMO nurse. I don't mind working with junior staff. Everybody would have to start somewhere, isn't it? But if you give me 2 of them, with 2 circuits, and a filter, too, my stress augments together with the work; babysitting can be more challenging than keeping the circuits running. He doesn't need to be highly skilled and overly knowledgable; he just needs to have good planning skills, can act fast in an emergency situation, and most important of all, he needs to have the basic common sense. It's sad sometimes that common sense is not very common.
I am an ECMO nurse. I know you have done ECMO before, but there is a reason why you don't do it now. So if I'm not in the bedspace, please don't manipulate the bed and go up and down without me supervising it. It is my name beside that ECMO circuit, and it is my registration that is on the line if something nasty happens. You probably know what you are doing, but please let's respect each other's role.
I am an ECMO nurse. I know you haven't had an exposure with ECMOs before, and I'm glad that you sometimes admit it. If I call for a registrar and you don't know what to do, I'll explain to you what's happening and I'll give you some suggestions on what we can do. If I tell you that we have been having suckdown events because the patent is not properly sedated, please don't order to give 500ml Albumin to an already fluid overloaded patient. You are making the situation worst and you are not solving the problem. One note for you: Fluids don't always solve suckdown events. Trust me, I learnt it the hard way.
I am an ECMO nurse. I sometimes do a 12-your shift without any break just because there's no other ECMO nurse in the hospital. I try not to drink heaps of water, for I know that going to the toilet will be a mission especially if there is an unstable circuit. I get offered a urine bottle sometimes by my lovely colleagues, but I don't think I'd go as low as that. I would rather run as fast as I can, and do the deed in less than a minute, than to wee in the same room where I work. There are just principles that you can't give up even in the tightest of situations.
I could rant more and sound like a overtly cocky nurse, but I am tired, so I'll end it here. It could be ugly and extremely stressful sometimes doing what we do, but looking at all the post ECMO patients make it all worth it. The little child could start playing with his classmates who sent him well wishes when he was very ill, and the teenager could continue university and marry his beautiful girlfriend who was at his bedside when he was literally on the edge of dying. And so on with the greatest success stories in my career. It's a very challenging role, I must say, and it all started when I finally was able to call myself an ECMO nurse.