After about two months of hospitalization, one of Oregon Health & Science University’s first patients with COVID-19 has finally been discharged.
Staff lined OHSU hallways on the afternoon of May 13 to cheer Maria Nevarez, 48, of Mattawa, Washington, as she left for home. As Nevarez was wheeled from her hospital room and passed through the group, she gave a shy smile and waved.
Nevarez’s long-awaited departure is largely due to a month she spent on advanced life support equipment that infused her blood with oxygen when her coronavirus-devastated lungs were unable to perform their normal tasks.
The complex equipment, called Extracorporeal Membrane Oxygenation, or ECMO, uses pumps and tubes to remove blood from a patient, inject it with oxygen, and return the oxygenated blood to circulate in the body. The process gives patients time to receive other treatments that help their lungs or heart recover and hopefully be able to work on their own again. ECMO is usually the last option for the sickest of patients, for whom traditional treatments no longer work.
Nevarez was too unstable to travel to OHSU from a hospital near her home in Washington state. So an OHSU team came to her, started the ECMO treatment there on March 16, and then transported her to Portland. Nevarez’s arrival came about a week after OHSU had its first presumptive patient with COVID-19 March 8.
The average ECMO patient is on the life-supporting equipment for two weeks, but coronavirus can cause more severe illness and prolong ECMO treatment. Nevarez was on ECMO for 30 days.
“When these patients need ECMO, they are just about as sick as someone can be without dying,” said Heather Mayes, R.N., an ECMO coordinator and intensive care nurse. “It took some time, but we started to see her make progress on ECMO, and her lungs were eventually able to do the work themselves. After she was moved out of the ICU, it was good to hear positive reports from other nurses who continued her care. It’s encouraging to see her make progress. It says ‘let’s keep trying,’ and gives us hope for future patients.”
The week before her discharge, Nevarez was asked what she wanted to share about her experience with the coronavirus. Because she had a tube in her throat to help her breathe at the time, she wasn’t able to speak. But she typed a Spanish message into her cell phone and passed it to a language translator, who read these words: “The hardest thing has been being away from my family.”
To prevent the virus’ spread, OHSU and most other hospitals made the difficult decision to limit visitors during the pandemic. Instead, health care workers have helped patients stay in touch with their loved ones through video and voice calls on personal and shared devices such as phones and tablets.
Of the 54 OHSU patients who had been hospitalized for coronavirus through May 13, three had been placed on ECMO.
Regional pandemic readiness
Before Nevarez was admitted, OHSU’s ECMO team was hearing as many as 11% of COVID-19 patients in China were being placed on ECMO. Normally, just 1% of critically ill patients are on ECMO. To prepare for a possible surge in ECMO use, which requires at least two nurses per shift per machine, OHSU rushed to train 10 new nurses on the specialized equipment.
To make matters worse, a key ECMO component -- disposable oxygenators -- is primarily made in Asia and Europe. Both areas were overwhelmed with coronavirus patients and unable to maintain normal manufacturing activity. As a result, OHSU had to switch to a different system and train staff on the new system’s use.
“ECMO machines are used as a last resort, so we generally only need a few,” said David Zonies, M.D., M.P.H., who directs OHSU’s Adult Extracorporeal Life Support Program. “I started to worry what would happen if the demand for ECMO machines exceeded supply in the U.S.”
If that happened, Zonies wanted to ensure the region’s ECMO machines were equitably and fairly made available to those who needed them. He reached out to about a dozen other Pacific Northwest health centers to create a regional ECMO collaborative that operated on a unified set of criteria for providing life support for patients. The group’s resulting crisis medical standard prioritizes those with severe respiratory failure despite receiving maximum ventilation and those who are most likely to benefit from ECMO, including those who don’t have multiple-organ failure or severe immunosuppression.
The regional collaborative also spurred the area’s ECMO centers to build a secure website that enables them to share how many of their machines are in use, how their ECMO patients are faring and more. If a patient needs ECMO, but their closest center doesn’t have one available, clinicians can look at the collaborative website to find the nearest available ECMO machine.
While Oregonians’ adherence to the state’s stay-at-home order has helped prevent a surge of coronavirus patients, the pandemic encouraged the region’s ECMO providers to combine forces. Zonies expects the new regional collaborative’s work to continue throughout this pandemic -- and any other future crisis that could strike the Pacific Northwest.
Extracorporeal Membrane Oxygenation at OHSU, by the numbers:
- 2 = Number of children who can simultaneously be on ECMO at OHSU Doernbecher Children’s Hospital
- 4 = Number of adults who can simultaneously be on ECMO at OHSU Hospital
- 3 = Number of OHSU coronavirus patients who have received ECMO treatment through May 13
- 354 = Total number of OHSU patients (adult and pediatric) who have received ECMO treatment since 2001
Pacific Northwest ECMO Collaborative members include:
- OHSU Hospital (Portland, Oregon)
- OHSU Doernbecher Children’s Hospital (Portland, Oregon)
- Legacy Emanuel (Portland, Oregon)
- Legacy Randall Children’s Hospital (Portland, Oregon)
- Providence Portland Medical Center (Portland, Oregon)
- University of Washington (Seattle, Washington)
- Harborview Medical Center (Seattle, Washington)
- Swedish Medical Center (Seattle, Washington)
- Seattle Children’s Hospital (Seattle, Washington)
- Mary Bridge Children’s Hospital (Tacoma, Washington)
- Tacoma General Hospital (Tacoma, Washington)
- Providence Sacred Heart Medical Center (Spokane, Washington)
- Kootenai Health (Coeur d’Alene, Idaho)