EDECMO Podcast

Zack Shinar, MD

The ED ECMO Project is the work of Zack Shinar and Jon Marinaro to bring extracorporeal life support to EDs and ICUs around the world. This site aims to be the ultimate resource for the background, logistics, and evidence for resuscitative ECMO.

  1. 5 Sept

    EDECMO 106: Working in the CT ICU with Mark Ramzy

    What happens when emergency medicine, cardiac surgery, critical care, ECMO, and human factors collide in the highest-stakes environment imaginable? Mark Ramzy takes us inside the CTICU to explore the art of resuscitation—and why knowing when to move fast, when to slow down, and how to work as a team may matter as much as the technology itself..   In this episode of ED ECMO, Zack Shinar sits down with Mark Ramzy, an emergency medicine–trained cardiothoracic intensivist, to explore what resuscitation looks like when the patient is already surrounded by ECMO, LVADs, invasive hemodynamic monitoring, recent sternotomy, and a highly specialized multidisciplinary team. Mark shares practical lessons from the CTICU, including how post-cardiac-surgery arrest algorithms differ from traditional ED resuscitation, when to shock rather than immediately perform chest compressions, how to recognize impending deterioration, and why knowing when to “speed up” and when to “slow down” can make all the difference. He discusses open-chest resuscitation, internal cardiac massage, VA ECMO as an exit strategy, and his experience with double sequential defibrillation. The conversation then moves beyond procedures into the human factors of high-stakes medicine. Mark describes working alongside cardiothoracic surgeons, interventional cardiologists, intensivists, nurses, respiratory therapists, and emergency physicians—and argues that successful ECPR depends less on territorial boundaries and more on recognizing what each member of the team brings to the table. Finally, Mark offers a cautionary perspective on the rapid expansion of ECMO and ECPR. As these technologies become increasingly accessible, he emphasizes the importance of quality control, mentorship, humility, and developing strong relationships across specialties. His overarching message is simple: medicine is a team sport, and the best resuscitation teams know not only what they can do, but when to listen, when to slow down, and when to let someone else lead.

  2. 9 Aug

    EDECMO 105: Becoming an ECMO Coordinator

    EDECMO 105: Becoming an ECMO Coordinator? In this episode, hosts Zack Shinar and Jon Marinaro are joined by Jonathan Goldstone, ECMO Coordinator at Sharp Memorial Hospital, and Rachel Wallace, ECMO Coordinator at the University of Minnesota ECMO Program, to explore one of the least understood but most important roles in an ECMO program—the ECMO coordinator. The discussion begins with recent advances in their own programs, including dramatic reductions in ECPR cannulation times at Sharp through improved teamwork, standardized equipment, and streamlined workflows. This sets the stage for a broader conversation about how successful ECMO programs are built and sustained. Rachel provides a detailed overview of the ECMO coordinator’s responsibilities, including onboarding and training ECMO specialists, competency assessment, simulation education, quality assurance, ELSO registry management, physician education, equipment evaluation, and research support. Jonathan emphasizes that while coordinator responsibilities vary between institutions, the central mission is always the same: ensuring there are no weak links in the ECMO system that could compromise patient care. The panel clarifies the often-confusing distinctions between perfusionists, ECMO specialists, ECMO coordinators, and ECMO managers, highlighting that ECMO specialists may come from nursing, respiratory therapy, perfusion, or advanced practice backgrounds, while coordinators oversee education, quality, systems improvement, and program development. The conversation explores how hospitals should think about hiring an ECMO coordinator, arguing that programs should invest in leadership early—even before case volumes become large—to build the infrastructure necessary for safe and sustainable growth. The guests also discuss how coordinators influence equipment purchasing, mobile ECMO development, process optimization, billing, and multidisciplinary collaboration. A recurring theme throughout the episode is that ECMO is fundamentally a team sport. The guests stress that efficient ECPR depends less on individual expertise and more on standardized processes, constant communication, simulation, and shared mental models among physicians, nurses, respiratory therapists, perfusionists, and ECMO specialists. Finally, the discussion turns to professional development for new coordinators. The guests encourage listeners to leverage the ECMO community through conferences, podcasts, ELSO resources, WhatsApp discussion groups, and mentorship from experienced programs. They conclude by emphasizing that ECMO practice continues to evolve rapidly, requiring coordinators and physicians alike to remain curious, adaptable, collaborative, and committed to continuous improvement. Key takeaways: The ECMO coordinator is the operational leader who integrates education, quality improvement, data management, research, equipment, and systems engineering into a cohesive ECMO program. Successful ECMO programs depend on standardized processes, simulation, and multidisciplinary teamwork rather than individual heroics. Every hospital must develop an ECMO program tailored to its own personnel, patient population, and resources rather than simply copying another institution’s model. Continuous learning, collaboration, and engagement with the broader ECMO community are essential for building and sustaining high-performing ECMO programs.

  3. 18 Mar

    EDECMO 103: HIV and ECMO

    Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak –   Episode 103 Key Points: ECMO in HIV/AIDS Patients 1. HIV Is No Longer a Strong Contraindication to ECMO Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO. With modern antiretroviral therapy (ART), outcomes have dramatically improved. Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy. Therefore, HIV alone should not exclude patients from ECMO candidacy. 2. Immune Reconstitution Makes Recovery Possible ART can rapidly suppress viral load and restore immune function. Patients with very low CD4 counts (even 800) over time. This means even severely immunocompromised patients may recover if given time and support. ECMO can act as a bridge to immune recovery. 3. ECMO Functions as a “Pause Button” ECMO stabilizes respiratory or cardiac failure while clinicians: Treat infections Start ART Manage complications This buys time for reversible disease processes to recover. 4. Major Cause of Respiratory Failure: Pneumocystis Pneumonia Common features in HIV patients requiring ECMO: Pneumocystis jirovecii pneumonia (PJP) Severe respiratory failure Cystic lung destruction Frequent bronchopleural fistulas and pneumothorax Ventilation can worsen these conditions. Thus ECMO is used to: Reduce ventilator pressure Prevent further lung damage Allow lung healing. 5. Ventilator Strategy: Minimize Positive Pressure Typical strategy: Rapid ECMO initiation if ventilation causes lung injury Attempt early extubation If needed: tracheostomy minimal ventilator settings Example “rest settings” described: Driving pressure ≈ 10 PEEP ≈ 10 (often reduced further) FiO₂ ≈ 50% Goal: avoid further lung trauma. 6. ECMO Candidate Selection Primary question: Is the disease reversible? If yes → ECMO should be considered. Factors supporting ECMO: Young patient Treatable infection Potential immune recovery Possible relative contraindications: Severe fungal infection Multiple uncontrolled opportunistic infections Extreme cachexia or severe systemic deterioration. 7. Early ART Should Be Started Modern approach: Start antiretroviral therapy during acute illness Do not delay until after ICU discharge Benefits: Rapid viral suppression Faster immune recovery Risk: Immune Reconstitution Inflammatory Syndrome (IRIS) Temporary worsening of infection due to immune rebound. 8. Circuit and Infection Complications Important ECMO considerations in HIV patients: Increased risk of circuit thrombosis Possible fungemia If fungemia occurs: circuit replacement possible re-cannulation These complications require careful monitoring. 9. Cannulation Strategy Example high-volume center approach: Bilateral femoral VV ECMO cannulation Fast Reliable flow Allows later neck access if needed Used especially during high-volume periods (e.g., COVID). 10. Outcomes and Indication Expansion ECMO indications are evolving: Older age Longer ventilator times HIV/AIDS Cancer patients All are examples of “indication creep” as experience grows. The key principle remains: ECMO should be used if there is a realistic chance of recovery. 11. Resource and Program Considerations Decision-making must consider: Resource availability Program experience Institutional risk tolerance High-volume ECMO centers can often accept higher-risk patients. 12. Broader Lesson Medical contraindications often change with new technology and therapies. Example given: HIV was once a contraindication for kidney transplantation Now it is accepted due to improved treatment. The same evolution may be happening with ECMO indications.

About

The ED ECMO Project is the work of Zack Shinar and Jon Marinaro to bring extracorporeal life support to EDs and ICUs around the world. This site aims to be the ultimate resource for the background, logistics, and evidence for resuscitative ECMO.

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