RNs running ECMO on adult patients

Dinith88 · May 2, 2010

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. I had a "crash course" for 10 minutes from our unit educator before taking over this very sick patient 45 minutes out of OR. I had a "helper" nurse who also was invaluable to run labs, help with IV's, and checking/hanging blood.
Now it seems I'm a seasoned veteran after two shifts of caring for this patient. I have been "asked" to attend a seminar so that I can run the ECMO myself. At first, I was a bit flattered then really got to thinking about it. Do I really want this responsibility? Do I really want to be on call 24/7 in case an ECMO case rolls through the door? Do I really want to save my department $$$ by doing this and getting no compensation for it myself?
I'm thinking NO!
I have heard that it is commonplace for RN's to run ECMO on adult patients. I just don't believe it. I think that is a perfusionist pervue and don't want the job, thank you very much.
What say you?
PBear

Dont be afraid of it. I say go for it.

People come to the ICU all the time who die...and will die regardless of what you do or what machine/machines we use...and...when they die it doesnt mean it's your fault or your responsibility or...

Or..a better idea... lets just give up all the techno-critical-care-type important machiney-stuff...and just wipe butts and pass meds. This will then let us feel less responsible..and less afraid.

ittybabyRN, RN · May 3, 2010

I work in a children's hospital so it may be a little different but we have RN's and RT's that are trained as ECMO techs that always run the pump side, our ECMO core team is made up of those trained people and when they are working and there are no ECMO pts they hang out until one comes in. If there are many ECMO pts and the ecmo team is all busy we always have extra trained RN's/RT's who are at work and will come out of their assignment if someone is going onto ECMO

As an RN I would need 5 years of experience before being able to be trained on the pumps

allnurses Guide · May 5, 2010

Hell yes! A big part of what I love about ICU is the toys. Adding skills and challenges = good for me.

You won't be putting them in or exchanging oxygenators, I imagine, so it's not really much different from managing balloon pump or VAD or ventilator. Just scarier looking.

armyicurn · May 11, 2010

Make sure you ask for more money when your next review comes around.

littleneoRN · May 11, 2010

I work at a Children's Hospital that does ECMO in the NICU/PICU. But the principles here are the same. My concern is not an RN running the pump. We have RNs trained to run the pumps. These are experienced PICU or NICU nurses who work some of their shifts in patient care and some running the pump. One nurse for the patient, one for the pump. For cannulation, decannulation, pump changes, etc, a perfusionist comes in to assist. In our hospital, you need to go to a class (8 hours I think) and have precepted shifts with an ECMO patient before caring for them. Then there is a whole separate training and preceptorship for the pump AFTER you have lots of bedside ECMO experience. So my concern is that your hospital thinks it's ok to throw you at a patient with a "ten minute crash course" and two shifts later, ask you to learn to run the pump. It just makes me nervous for you and your license that the hospital would not put a higher value on training, education, and some bedside experience. I would definitely recommend getting pump trained if it interests you and you get some more bedside experience with ECMO, but I would ask lots of questions about the training (classroom and patient care) you would receive, available resources, and expectations. Seems a little fishy to me.

ECMORN · Jul 8, 2011

ELSO (Extracorporeal Life Support Organization) has specific guidelines for the training of healthcare personnel caring for ECMO patients. There are also companies like ECMO Advantage http://www.ECMOAdvantage.com that will provide training courses and other services to institutions interested in ECMO Support.

It is important to consider what happens to the care givers who take on this responsibility without proper training. I am aware of law suites where the Nurse was named specifically because an event occurred and no one knew how to respond to it resulting in injury to the patient. Of course we all know the legal liability risks we take every day in the critical care environment. But do you really want to take that risk without at least being able to say that you were trained to provide the care according to some standard (i.e. ELSO)?

I believe we are going to be seeing a lot more of Adult ECMO. It will be important to make sure all caregivers are properly prepared to provide this support.

IDoNotGiveOut · Jul 1, 2012

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. :)

umcRN, BSN, RN · Jul 2, 2012

IDoNotGIveOut - I couldn't agree with you more! I've worked 3 years now in NICU/Peds CICU and done bedside ecmo plenty of times. People keep telling me I should take the class for ECMO specialist and I feel in NO way ready to bear that responsibility. Nope, no thank you. Maybe some day but personally I like nursing the patient, not a machine and I'm not ready yet to be the one in "charge" of an ecmo emergency. The last ECMO emergency I witnessed involved an infant...and everyone in the room had to throw out their scrubs and shoes and the walls & ceilings had to be repainted/renovated - there was that much blood. (I didn't take care of the kiddo, was on the other side of the unit and happened to walk by and witness it...there were enough people in there and I just kept going, I liked my scrubs that day :eek: )

PMFB-RN, RN · Jul 2, 2012

It's up to you. I can tell you that in our ICU RNs run ECMO. We have a number of RNs who are trained to manage the ECMO and they are alwasy assinged with another ICU RN for a 2:1 nurse / patient ratio. We do NOT have a prefusionist running things, just RNs with perfusionist on call for support. Personaly I have a blast running ECHO and always choose those patients. I am alwasy thrilled to learn new skills and recieve more training. Not everybody is the same.

IHeartDukeCTICU · Jul 13, 2012

I'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.

allnurses Guide · Jul 13, 2012

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. :)

With 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.