Part two of two. Part one, “First 5 Minutes,” covers why the first five minutes back in the room are the most dangerous, and why a thing that’s connected isn’t necessarily working. This is the walkthrough.

The reset, again, in order: Cannula, Power, Oxygen, Water, Sweep and settings, Alarms, Data. Here’s what each one actually catches.

C — Cannula

First, because it’s the only item that can kill in seconds.

Three checks: securement (sutures, clip, and dressing intact), external position (the depth marking at the skin matches your documented number — you should know that number cold), and the site itself (no kinks, no new bleeding).

The fear isn’t only frank decannulation, though that’s catastrophic. The subtler enemy is migration. A drainage or return cannula pulled back during a slide gives you suck-down, chatter, recirculation, or a number of other issues. The external mark can even look fine while the tip has moved. Don’t let a happy pump talk you out of looking. In peripheral VA, “C” is plural, don’t forget the distal perfusion cannula and the limb it’s keeping alive.

P — Power

Both ends. The AC cable into the wall and the cable seated in the machine. Then confirm the indicator that says it’s actually on mains and charging — not just that a plug is in a hole.

Two traps. First, the wrong outlet: use the emergency/backup-power outlets, not a regular one. Second, trusting the battery. The battery is your transport bridge, not your home base. If you don’t restore mains power, the machine runs the battery down silently. It will usually start alarming with plenty of reserve, but you will loose a vote of confidence from the relatives that are sitting in their loved ones room. “Plugged in” with no charging indicator is the false reassurance in its purest form.

O — Oxygen

Two reconnections, not one, and both have to happen. First, the blender on the ECMO cart gets plugged into the wall — wall oxygen and wall air. Then the oxygenator’s gas tubing comes off the transport tank and connects to the sweep flowmeter on the cart, which is fed by that blender, which is now fed by the wall. The whole supply path is wall → blender → flowmeter → oxygenator.

The trap is doing half of it. Plug the blender into the wall but leave the tubing on the tank, and the blender’s live while the patient’s gas is still coming from a cylinder you’ve been draining all trip. As long as the tubing’s on the tank, you’re living on what’s left — and it’s less than you think. A lot of tanks have an alarm that goes off at 500 psi, but you will loose another vote of confidence with the loved ones that are sitting in the patient’s room. Move the tubing onto the wall-fed flowmeter and you’re finally off the countdown.

W — Water (the heater-cooler)

The order matters here, and it’s the one people get backwards. Warm the heater first, then connect it. Power the unit and let it circulate in its own loop until it reaches target temperature, and only then connect the water lines to the oxygenator. Warm to warm.

You have to understand the starting state to see why. We generally don’t warm the patient during transport — they run passive by design, and the heater goes on once we’re back in the room, or in the OR for an extended case. So on arrival the unit has been off the whole time and it’s cold. That’s the expected state, not an exception. And the instinct, when you want warming started fast, is to plug it straight into the oxygenator. That instinct is the trap.

If you connect a cold heater to the oxygenator and then let it warm up, and you’ve plumbed a room-temperature exchanger into the circuit, actively pulling heat out of the patient for as long as the catch-up takes. They were holding steady on passive transport; now you’re cooling them.

This is where pediatrics is unforgiving. A small child has little thermal reserve and a circuit blood volume that’s large relative to their own, so a cold exchanger doesn’t nudge their temperature, it drags it down fast and deep. The consequences stack: coagulopathy in an already anticoagulated patient, arrhythmia, rising oxygen demand, and real distress for a child who can feel every bit of it. It can genuinely shock them. Adults have more buffer, but the principle holds. Get it to temperature, then bring it to the blood.

S — Sweep and Settings

This letter does double duty, and both halves are easy to skip in the rush.

Sweep first, because it’s the killer, and because the letter “O” only got the tubing onto the flowmeter. It did not confirm gas is moving. The flowmeter can sit at zero, or at the wrong number, with the tubing perfectly connected. So come back to it on its own and confirm the sweep is on and set to the right level. You probably eyeballed it during the tubing move; check it again anyway, separately, on purpose. Sweep-off is an emergency that doesn’t announce itself on the console.

Then the rest of the settings, because transport settings persist. You may have run a higher flow during the move or set FdO2 to 100% for the trip. Now the machine is quietly delivering the wrong therapy behind a normal-looking display. Walk the numbers against the order: pump RPM and target flow, sweep rate, blender FiO₂, and heater target.

Settings is the capstone of the “Connected Is Not the Same as Working” idea. It doesn’t ask if it’s plugged in. It asks if it is set to the right number.

A — Alarms

Restore the limits, high and low flow, circuit pressures, and delta-P if you trend it. Un-silence anything you muted for transport. Confirm the air/bubble detector and intervention is turned on.

Alarms come near the end on purpose: they’re the safety net for everything above. If the cannula migrates an hour from now, if the flow drops, pressures change, if power quietly drops to the battery, alarms are what tell you. A silenced or widened alarm means everything you just confirmed has no backstop. You set alarms after you’ve set the values it’s watching, which is why “A” follows “S.”

D — Data

Reconnect the data cable so the console transmits to the chart and to central monitoring.

It’s last for an honest reason: it’s the only item that won’t hurt the patient in the next five minutes. But it isn’t optional. Lose it, and you lose trending, the documentation trail, remote visibility, and alarm routing to the station. Last in priority. Not skippable.

The bottom line

C-POW-SAD is a connection-and-configuration check for the highest-risk five minutes in an ECMO patient’s day. Its job is to defeat the false reassurance of something that’s present but not working. Treat this as a non-negotiable task. Don’t trust the calm console: after a move, the machine looking normal is the beginning of the check, not the end of it.

Learn more

For more practical ECMO articles and study tools, look around on this website LifeSupport.Training and subscribe to this newsletter ECMO 143: AI-Assisted Journey.

I also built AI ECMO Educator, a free-to-use tool that provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. It draws from sources such as ELSO, PubMed, AmSECT, and leading centers.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

Tokyo may be my favorite city in the world now.

It used to be Singapore, and I still love Singapore, but the humidity there is brutal. Tokyo feels different. It is huge, but somehow quiet. It is busy, but it does not feel chaotic. People move with purpose. Trains are clean. Streets are orderly. Even when there are people everywhere, the city still feels calm.

This is my second time in Tokyo, and I am loving it even more this time.

I am staying in a small hotel in the Shimbashi area. The room is small by American standards, but it works. It is clean, efficient, and practical. That seems to be a theme here. Space is used carefully. Nothing feels wasted.

The food has been phenomenal.

There are tiny restaurants everywhere. Some have just a few seats. Some are tucked into narrow streets or hidden in plain sight. Many seem to do one thing very well. You walk past a small doorway, look inside, and there is someone working quietly behind a counter with more precision than a lot of full restaurants back home.

I went to dinner with colleagues and ate eel. It was excellent. Not just good, but memorable. The kind of meal that makes you slow down and pay attention.

Then there are the convenience stores.

I know this sounds ridiculous if you have only experienced convenience store food in the United States, but 7-Eleven in Japan is better than a lot of fast dining restaurants back home. The sandwiches are good. The rice balls are good. The drinks are good. The prepared meals are good. It is fast, clean, affordable, and reliable.

At one point, I got creamy corn out of a coffee machine. The same machine also had bone broth. In the United States, a machine like that would probably give you burnt coffee and something pretending to be hot chocolate. In Tokyo, it gives you hot corn soup and bone broth.

Everyone has been kind. Not loud. Not performative. Just kind. The taxi drivers are professional. The servers are polite. People seem willing to help, even with a language barrier. Taxis also do not cost an arm and a leg, which has been a pleasant surprise.

Tipping is different here, too. As an American, it is hard to turn that habit off, but here it feels unnecessary and even surprising to people. Service does not seem built around chasing tips. It feels built around doing the job well.

That has been one of my biggest impressions of Tokyo so far.

The city works because details matter. The trains work because details matter. The food works because details matter. The small hotel room works because details matter. Even a convenience store meal feels better because someone cared about the small things.

That mindset connects directly to ECMO.

Because ECMO is also built on details.

APELSO

I came to Tokyo for the 8th Annual APELSO Conference, held June 11 through 13, 2026. APELSO was packed with opening lectures, global ECMO updates, education sessions, mobilization talks, anticoagulation discussions, ventilation strategy, pregnancy ECMO, transport, and program development.

But the main theme was clear to me: ECMO is not just a machine. ECMO is a system.

A pump and oxygenator do not make an ECMO program. A program is built from trained people, clear roles, practiced responses, honest data, good communication, and a culture that can admit what it does not know.

One line that stuck with me:

Without data, all we have are opinions.

That is painfully true in ECMO.

ECMO is full of strong opinions. Ventilator settings. Anticoagulation. Cannulation strategy. Transport planning. Mobilization. Staffing. Specialist training. Everyone has a way they like to do things. But if we are not collecting outcomes, comparing practices, and challenging our assumptions, we may only be defending habit.

That is one reason ELSO registry work matters. It is also why education and certification matter. ECMO is too complex, too expensive, and too high-risk to expand without structure.

One of the strongest themes was early mobilization.

The message was not simply, “Walk the patient.” It was bigger than that. It was about reducing sedation, preserving strength, and aiming for survival that means something after the ICU. Getting someone off ECMO is not enough if the patient is left profoundly weak, delirious, and unable to recover a meaningful life.

The talks on verticalization therapy and structured mobility were practical. Tilt beds, staged mobility, safety checklists, and team coordination all matter. But the bigger point was that equipment alone does not create a mobility culture.

A tilt bed helps. A special chair helps. A protocol helps. But none of it works if the team is afraid, untrained, understaffed, or unclear about who owns the process.

That same lesson showed up again in the transport sessions. The ECMO transport material was among the most useful content, whether for air, ambulance, or in-hospital transport. Transport is where ideal plans meet reality. Oxygen estimates may be wrong. Batteries may drain faster than expected.

The transport message was simple: safety is built before movement.

Check the oxygen. Check the battery. Check the power source. Check the backup plan. Check who is watching the cannulas. Check who owns the pump. Check who communicates with the driver, pilot, sending team, receiving team, and physician. That sounds basic until you realize how many disasters come from basic things being assumed rather than confirmed.

The nursing education sessions also stood out.

Nurses are not passive participants in ECMO care. They are often the first to recognize deterioration. They are at the bedside continuously. They see the patient, the circuit, the ventilator, the labs, the family, the sedation pattern, the bleeding, the clot burden, the neurologic changes, and the small signs that something is starting to shift.

Good ECMO nursing education cannot be limited to task training should not only ask, “What would you do?” It should ask, “What are you seeing? What do you think is happening? What else could explain it? What information do you need next? What is dangerous right now? What can wait?”

That is how expert thinking becomes teachable.

The anticoagulation discussion made the same point from another angle. Protocols matter, but protocols are not enough. ACT, aPTT, anti-Xa, platelet count, fibrinogen, hemolysis, inflammation, antithrombin, liver function, renal function, circuit inspection, bleeding, and clot burden all tell part of the story.

A single number cannot manage an ECMO patient.

The bedside picture matters. The circuit matters. The patient phenotype matters. The trend matters.

That is real ECMO. The anti-Xa may look fine while the oxygenator is telling a different story. The aPTT may be elevated, but the patient is inflamed. The protocol may point one way, while the patient in front of you is telling you to slow down and think.

The sessions on VV ECMO ventilation, pregnancy ECMO, and cannulation strategy added even more depth. The VV ECMO material reinforced the need to reduce ventilator-induced lung injury, minimize driving pressure, personalize PEEP, and avoid assuming that lungs cannot recover too early. The pregnancy ECMO talks were a reminder that maternal physiology changes the targets. Oxygenation, carbon dioxide, flow needs, cannula choice, anticoagulation, fetal monitoring, and delivery planning all become more complex.

I was tired, but it was the good kind. The kind where your brain is full because you actually heard things worth thinking about.

The big takeaway for me is that ECMO care is moving beyond the idea of heroic rescue. Rescue still matters. There will always be emergencies. There will always be crashing patients, hard cannulations, bad gases, clots, bleeding, alarms, transport problems, and difficult decisions.

But the future of ECMO is not just rescue.

It is systems. It is education. It is transport planning. It is nursing judgment. It is honest data. It is regional collaboration. It is known that buying equipment is not the same as building a program.

Tokyo has been the perfect place to think about that, because this city makes details visible. The calm is not accidental. The order is not accidental. The food, trains, hotels, taxis, and tiny restaurants work because people pay attention to the small things.

ECMO is the same. The details are not decoration. The details are the care.

There was far more than I could include in one article. I will continue sorting through the sessions, notes, and ideas as part of the ongoing ECMO 143 learning journey.

ECMO 143 creates practical ECMO education, articles, and learning tools for clinicians who want to better understand the work behind the circuit. Subscribe to LifeSupport.Training to be notified when new articles from ECMO 143: AI-Assisted Journey are published.

Part one of two. Part two walks through CPOW-SAD letter by letter.

Transport gets most of the attention: the packing, the battery math, the oxygen tank, the elevator, the door frames, the trip there and the trip back. And it should. Moving an ECMO patient is one of the riskiest things we do.

But I have learned to respect the moment right after transport just as much.

Back in the ICU room. Back from CT. Back from the OR. The patient is settled. The team is busy. Everyone exhales a little. That exhale is the problem. The first five minutes after a move may be the easiest time to miss a preventable error, because everything looks like it is back where it belongs.

So I run a reset every time. The mnemonic I use is CPOW-SAD:

• C - Cannula

• P - Power

• O - Oxygen

• W - Water

• S - Sweep and settings

• A - Alarms

• D - Data

That sequence is not random. Secure the patient. Restore the supplies the machine depends on. Confirm the machine is running at the right settings. Arm the safety net. Make sure the data is transmitting. Part two will walk through each letter in detail. This first part is about the idea underneath the mnemonic.

The main idea: connected is not the same as working

If you remember one thing, remember this: connected is not the same as working.

After a move, the danger is not always that something is missing. Often, the danger is that something is present but not doing its job. The power cable may be in the wall, but not seated in the machine. The gas tubing may be connected, but the flowmeter may still read zero. The heater-cooler lines may be hooked up, but the unit may still be cold. The cannula may still be sutured, but it may have shifted during the slide from bed to table, or table to bed.

Everything looks attached. The console looks calm. That is the trap.

CPOW-SAD is not a “did I plug it in?” list. It is an “is it actually functioning?” list. Every letter asks the harder question. Not just, “Is it there?” but “Is it secure? Is it powered? Is gas actually flowing? Is water warm and circulating? Are the settings back where they should be? Are the alarms armed? Is the data transmitting?”

Why this matters after transport

There is a reason this happens after transport. The team is task-saturated. Everyone is trying to get the patient settled. Sources are being switched from portable to wall. Cables are being moved. Tubing is being reorganized. The patient has just been moved from one surface to another, and anything taped, sutured, clipped, connected, or positioned can shift.

That combination matters: high workload, physical movement, source changes, a quiet console, and a team that thinks the hard part is over.

That is exactly when a reset helps. A pump can be spinning at full flow with the gas off. A cable can sit in the wall and charge nothing. A circuit can look perfect while two centimeters of cannula migration changes everything. So I do not trust the calm console. I walk it.

Do not leave the room SAD

There is a hook inside the hook. The front part is familiar: CPOW. Cannula. Power. Oxygen. Water. Those are the visible things. They are easier to remember because they feel physical.

But the back half matters just as much: SAD. Settings. Alarms. Data.

Those are the ones I see skipped most often, because they are less visible. Nothing falls on the floor when you forget them. The patient may simply drift in the wrong direction, unwatched or undocumented. That is why the tail does its own work: do not leave the room SAD.

Before I leave, I want settings correct, alarms armed, and data flowing.

A shorter version like POW is easier to remember, but look at what it drops: cannula and sweep. Those are high-stakes checks. Shorter is not always safer.

Saying it out loud

When a family member is at the bedside, I will sometimes run CPOW-SAD out loud. Not dramatically. Just calmly: “I’m checking the cannula. Now power. Now oxygen. Now water. Now sweep and settings. Now alarms. Now data.”

That does three things. First, it reassures them. They see deliberate care instead of silent activity around tubing and machines. Second, it steadies me, because explaining the steps gives my own focus somewhere to go. Third, it forces honesty. You cannot say “power is on AC and charging” out loud while staring at a battery icon and not catch the problem.

The person at the bedside becomes part of the check. That is not bedside manner added at the end. It is part of the method.

The point

For me, CPOW-SAD is less about memorizing letters and more about respecting the first few minutes after a move.

That is when small misses hide in plain sight.

A cable can be present but not charging. Tubing can be attached but not flowing. A cannula can look secure but still move. So I try not to rush that moment. Connected does not mean it is working until I confirm it.

Next: Part two, CPOW-SAD letter by letter. What each check actually catches at the bedside.

Learn more

For more practical ECMO articles and study tools, look around on this website LifeSupport.Training and subscribe to this newsletter ECMO 143: AI-Assisted Journey.

I also built AI ECMO Educator, a free-to-use tool that provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. It draws from sources such as ELSO, PubMed, AmSECT, and leading centers.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

Recently, I heard about a patient with SAM, systolic anterior motion of the mitral valve. I had never heard of it before, and even after it was explained, I still had questions. That’s been happening more often. Adult ECMO patients don’t just come with diagnoses. They come with physiology that is not always obvious at the bedside.

We often describe ECMO as a bridge to recovery, transplant, device, or decision. But that only helps if we are clear about what the patient is being bridged from. Most of the time, the real problem is not the diagnosis itself. It occurs when the body can no longer deliver oxygen to tissues safely.

When I say oxygen delivery, I do not just mean oxygen in the blood. I mean, oxygen actually reaching the organs. That depends on several things working together: the lungs have to oxygenate the blood, hemoglobin has to carry that oxygen, the heart has to move blood forward, and the circulation has to get that blood to the tissues. If any part of that system fails badly enough, the patient may start moving toward ECMO.

That shift changed how I think about ECMO. Instead of starting with disease labels, I am trying to start with a simpler question: what part of oxygen delivery has failed?

ECMO Is a Bridge, but the Failure Comes First

A patient does not go on ECMO simply because they have pneumonia, ARDS, myocarditis, pulmonary embolism, or cardiogenic shock. Many patients have those diagnoses and never need ECMO. ECMO enters the conversation when something more fundamental breaks down. Either the body can no longer maintain oxygen delivery, or the support required to maintain it is starting to cause harm.

I needed a way to organize that at the bedside. Not a protocol, just a way to think through what is actually failing.

Here is the simple framework I am using:

This is simplified. Real patients do not stay in clean categories, and support strategies often overlap. But it gives me a place to start.

Lung Failure: When Gas Exchange Breaks Down

In lung failure, the main problem is gas exchange. The heart may still be able to move blood forward, but the lungs cannot oxygenate the blood, remove carbon dioxide, or do either without causing further injury from the ventilator.

This is where VV ECMO usually makes sense. It takes over gas exchange while the patient’s own heart continues to provide circulation. The important question is not just whether the oxygen level is low. It is whether the lungs are the main failed system, and whether the heart can still move blood forward.

Pump Failure: When Flow Is the Problem

In pump failure, the issue is different. The blood may contain oxygen, but the heart cannot move enough of it to the tissues. Oxygen is present, but it is not getting where it needs to go.

This is what we are really dealing with in cardiogenic shock. The problem is not just a weak heart. The problem is inadequate flow and poor tissue perfusion. VA ECMO can support circulation in this setting by providing flow and pressure while the team treats the underlying cause or decides what comes next.

Sometimes the heart recovers. Sometimes it does not. The next step may be a temporary device, a durable VAD, transplant evaluation, or a difficult conversation about goals of care.

Right Heart Failure: When Blood Cannot Reach the Lungs

Not all heart failure is left-sided. In pulmonary embolism, severe pulmonary hypertension, or acute right ventricular failure, the right ventricle cannot move blood through the lungs.

If blood cannot get through the lungs, it cannot be oxygenated. It can also not fill the left side of the heart. Over time, that leads to reduced systemic perfusion. So the problem is not just “heart failure.” The problem is that blood is not making it through the pulmonary circulation.

When the Picture Is Mixed

Some patients do not fit neatly into one category. A patient with severe ARDS may also have septic cardiomyopathy. A post-arrest patient may have both lung injury and myocardial stunning. A patient on VA ECMO may develop differential hypoxia, in which the upper body receives poorly oxygenated blood from the native heart and lungs, while the lower body receives oxygenated blood from the ECMO circuit.

In these cases, the physiology is mixed. Both gas exchange and circulation may be failing. This is where hybrid strategies come into play. I try not to start with the configuration. I try to stay with the underlying problem.

If gas exchange is failing, that needs support. If circulation is failing, that needs support. Sometimes both need attention at the same time.

When Support Becomes Part of the Problem

Another piece I am paying closer attention to is the cost of conventional support. Sometimes, ECMO is considered not only because the patient is deteriorating, but because the treatments required to keep them stable are causing harm.

High ventilator pressures can worsen lung injury. Severe acidosis can destabilize the patient. Increasing vasopressor doses may maintain blood pressure while tissue perfusion continues to fail.

ECMO adds risk. It is not a neutral intervention. So it has to create a path that did not exist before. That path might be recovery, transplant, a device, an intervention, or simply time to understand whether recovery is possible.

The Question I Am Trying to Ask Better

The SAM case reminded me how much I still have to learn, but it also changed the question I want to ask. When I hear that a patient is going on ECMO, I do not only want to ask what diagnosis they have.

I want to ask what physiology failed, and what we are trying to buy time for.

That feels like a clearer way to understand ECMO as a bridge. Not just a bridge to something, but a bridge from a specific physiologic failure toward a specific possible next step.

Disclaimer

This article is for educational purposes only. It reflects my ongoing learning as an ECMO specialist and does not replace clinical judgment, institutional protocols, or guidance from your ECMO team.

I ran into something at the bedside that didn’t make sense at first.

We had a patient on higher ECMO flows, and the pressure drop across the oxygenator (delta P) was elevated but appropriate for the settings we were running. About a week later, we had weaned the flow down, and the delta P dropped.

Looking at the numbers, it looked like an improvement.

But the oxygenator didn’t look better. If anything, it looked worse, fibrin on the faceplate, thrombus starting to show in the corners.

That created a mismatch I couldn’t ignore. The circuit looked worse, but the number looked better.

The Problem With Delta P Alone

I was taught that delta P is tied to flow. If you increase flow, the delta P increases. If you decrease the flow, delta P decreases.

So when we lowered the flow, the drop in delta P didn’t necessarily mean the oxygenator improved. It just meant we were asking less of it.

The Question We Always Ask

When delta P starts to rise, experienced ECMO specialists usually ask:

• “Is the flow the same?”

That’s the right question. Because if flow increases, a higher delta P may mean nothing at all. But here’s the problem: most of the time, that’s where the conversation ends. We acknowledge that flow matters, but we don’t have a simple way to account for it at the bedside.

So we’re left guessing:

• Was the change in delta P expected because of the change in ECMO flow?

• Or is the circuit actually getting worse?

Adding One Simple Layer

Out of curiosity, I started looking at delta P relative to flow:

• delta P ÷ ECMO flow = mmHg/LPM

At the start, this value was around 6 mmHg/LPM. About a week later, even though delta P had decreased, that number had risen to around 10 mmHg/LPM.

That changed the picture.

The circuit now required more pressure per unit of flow than before. And that matched what I was seeing.

What That Suggests

As an oxygenator develops clot or fibrin buildup, blood flow becomes less efficient. Pathways narrow, resistance increases, and more pressure is needed to move the same amount of blood.

If flow is decreased at the same time, that increase in resistance can be hidden. The raw delta P looks better, but the underlying problem may still be progressing.

Keep It in Perspective

This isn’t a perfect measurement. Hematocrit, temperature, and viscosity all affect the delta P.

And it doesn’t replace what we already watch: gas exchange, hemolysis, or visual inspection of the circuit.

But it adds one useful question:

• Is the circuit requiring more pressure than it used to for the same flow?

Bedside Takeaway

A lower delta P doesn’t always mean a better oxygenator, especially if flow has changed.

Sometimes you have to look one step deeper.

Learn more

For more practical ECMO articles and study tools, visit ECMO 143: AI-Assisted Journey.

I also built AI ECMO Educator, a free-to-use tool that provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. It draws from sources such as ELSO, PubMed, AmSECT, and leading centers.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

Key Points

• Ventilator withdrawal often involves unresponsive patients; emotional connections are primarily with family members.

• ECMO withdrawal may involve awake and interactive patients, creating deeper, more personal clinician-patient bonds.

• Clinical triggers for both include lack of recovery and complications, but ECMO decisions often hinge on transplant eligibility or irreversible organ failure.

• Emotional weight differs: Ventilator withdrawal leans on familiarity and structure; ECMO withdrawal often feels raw, personal, and ethically complex.

• Professional growth as an ECMO specialist challenges long-held norms from decades in respiratory therapy.

After 20 years as a respiratory therapist and now stepping into my role as an ECMO specialist, I’ve begun to see just how different these worlds can be, especially when it comes to withdrawing life support.

Through ECMO 143: AI-Assisted Journey, I’ve been documenting what I’m learning in real time. One experience I’ll never forget: a patient who was awake, smiling, and walking while on ECMO—who got married in the hospital chapel just days before she died. That moment was sacred. Beautiful. And it broke me a little.

It also taught me something no textbook ever could: stopping ECMO is not the same as stopping a ventilator. Not by a long shot.

Ventilator Withdrawal: Connection Through Families

Ventilators support patients with brain injuries, sepsis, or advanced terminal illness. When those patients are unresponsive, comatose, or brain-dead, I don’t form a personal bond. My role is focused and technical: manage the ventilator, adjust settings, and watch the numbers.

The emotional connection, when it comes, is with their loved ones.

Common Triggers:

• Brain death confirmed via EEG or imaging

• Advance directives or clearly communicated goals of care

• Lack of improvement over weeks or months

My Role:

Withdrawal is a team effort. Family meetings, ethics consults, and palliative care support help create clarity. We explain what happens during extubation. We manage sedation. I control the ventilator’s final settings. And then I stay in the room.

I’ve seen spouses whisper final prayers. Daughters hold their father’s hand while jazz plays softly in the background. It’s often peaceful, sometimes fast, and almost always surreal.

Emotionally?

I carry the family’s grief, not the patient’s. These moments are solemn, but familiar. I’ve done it hundreds of times. There’s structure. There’s closure.

ECMO Withdrawal: Bonds With Everyone

ECMO is different. It doesn’t just keep someone alive, it becomes the reason they’re alive. And many ECMO patients aren’t unconscious. They’re awake. Smiling. Talking. Living.

That changes everything.

Common Triggers:

• No recovery after lung or heart assessment

• Transplant is no longer viable

• Infections or complications make continuation futile

• Shared decision-making with patients or families choosing quality over quantity

My Role

We speak with the patient, if they’re awake, or with their family. The physician in charge and various team members explain that continuing ECMO is no longer helping and that it may now be causing more harm than good.

Stopping flow means death, usually within minutes. We sedate. We clamp the circuit. We stay by the bedside. But this time, we are not just supporting the family. We are grieving with them.

Because I knew her. I was elated when she stood up for the first time. PT, OT, the nurse, and I helped her into a chair. I listened to her joke with her husband—watched him tease her, make her laugh. She was real to me. And now, I’m part of letting her go.

Emotionally?

It’s different. Harder. Watching a fully alert human being die is tough. Sadness. Like I’m stepping away from someone I knew. The loss is heavier because the bond is deeper.

Years ago, I worked in international TV news. I was in places where people died right in front of me—disasters, conflict zones, moments that never leave you. This felt strangely familiar. The stillness. The heartbreak. The helplessness.

Key Differences

In ventilator withdrawal, my connection is usually with the patient’s family. The patient is often unresponsive, and the clinical decision is based on clear signs of non-recovery, brain death, or prolonged lack of improvement. Emotionally, the process is familiar, structured, and centered around helping the family say goodbye. My role feels practiced, technically grounded, and confident.

In ECMO withdrawal, the relationship shifts. I often know the patient well, and they’ve been awake, talking, and even mobilizing. The triggers for withdrawal are more complex: irreversible organ failure, transplant no longer an option, or complications like sepsis or bleeding. The emotional burden is heavier. It feels raw, personal, and centered not just on the family’s loss, but my own. My role is newer, more uncertain, and deeply vulnerable.

Final Thoughts

Ventilator withdrawal gives me a script to follow, a structure. I’ve rehearsed it, refined it, and lived it for years.

ECMO withdrawal? There’s no script. Each case writes its own story. Sometimes the ending is peaceful. Other times, it hits like a punch to the chest.

I once had a family ask if another ECMO Specialist could be present for the withdrawal instead of me. They felt closer to that person. I quickly agreed and stepped aside; it’s not about us. It’s about them—the patient and their family. Our job isn’t just to save lives—it’s to honor them. Even when that means quietly stepping out of the room.

Through ECMO 143 and LifeSupport.Training, I’ll keep sharing these lessons—because maybe someone else out there is just starting to see the contrast, too.

📝 Note: This article is for educational purposes only and is not a substitute for professional medical advice. Always consult with qualified healthcare professionals for clinical decisions and patient care.

🚀 Join the ECMO 143 Learning Journey. Enjoyed this? Subscribe to my free newsletter, ECMO 143: AI-Assisted Journey, on LinkedIn, where I share ongoing lessons as I learn and grow in ECMO and critical care.

🧠 Resources & Acknowledgments

I created this article using a mix of AI-assisted research and personal study. I’ve built two custom GPTs to support this work:

• AI ECMO Educator

• Micro Definitions (MD-GPT)

Special thanks to:

• OpenEvidence

• Claude 4.6 Sonnet

• Perplexity AI

• Gemini 3.1 Pro

• Stanford’s STORM

• Grammarly

• Leonardo AI

• DALL·E 3

• Microsoft Designer

• Adobe Express

🌐 My Other Links

• ECMO 143: A Patient & Family Guide

• LifeSupport.Training

• YouTube – ECMO 143 Channel

• LinkedIn – ECMO 143 Company Page

• Facebook – ECMO 143 Page

• X (Twitter) – ECMO 143 – UpToDate List

I met Shane in an ECMO survivor support group. His story stopped me. I reached out and asked if he’d be willing to share it here, and he said yes. What follows is his account of what it felt like from the inside — waking, recovering, and understanding what his team had done to keep him alive.

Shane went to bed one night thinking about the coming weekend. Hours later, he was in cardiac failure, on a ventilator, then on ECMO. What followed was survival — and a journey most clinicians never fully see from the patient’s side.

When Shane woke from the coma, nothing made sense. His world had shrunk to a narrow strip of glass, six feet by two feet. He couldn’t speak. He couldn’t move. He was losing track of words halfway through sentences. “I felt small, like I had lost something fundamental,” he writes.

But one thing stood out to him: the advocate at his bedside. His partner asked what they were giving him. Why. What each step meant. “Those questions helped bring clarity in the middle of chaos, when everything was moving quickly, and understanding felt just out of reach.”

Shane’s recovery took him through complications most of us hope our patients never face. He lost a leg to the brutal tradeoff of pressors. He gained forty pounds of fluid. He had to relearn how to breathe.

And here’s what he understands now that matters most for your team: “No one comes back from something like this alone. Survival does not belong to one person. It belongs to the families who stayed, the friends who hoped, and the doctors, respiratory therapists, nurses, techs, specialists, and teams who never gave up, even while living through hell themselves and praying for a miracle.”

That’s professional knowledge. Your patient sees it. They feel it. They remember it.

Read Shane’s full story on ECMO 143: A Patient & Family Guide, my free patient and family resource for anyone navigating ECMO.

Learn more

For a deeper dive into ECMO for professionals, subscribe to this Newsletter ECMO 143: AI-Assisted Journey, a free resource for specialists and trainees.

I also built AI ECMO Educator, a free Custom GPT providing evidence-based guidance on physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

As an ECMO specialist, I often find myself dealing with a variety of terms used to describe ECMO circuit components. I found out that different centers, teams, and even individual providers may use different language for the same part of the ECMO circuit. To ensure clear communication and avoid confusion, it’s helpful to recognize the most commonly used terms and be aware of less common alternative names.

ECMO Drainage vs. Return: What’s the Difference?

The ECMO circuit consists of two primary functions: drainage and return.

• Drainage: Deoxygenated blood is withdrawn from the patient into the ECMO circuit, usually via a venous cannula.

• Return: Oxygenated blood is returned to the patient via a vein (VV-ECMO) or an artery (VA-ECMO).

There are many names for these functions, so I compiled a chart to clarify the most commonly used terminology, along with less common alternatives.

Why Does This Matter?

Clear communication is critical in ECMO management. If team members use different terminology, it can lead to misunderstandings during patient handoffs, troubleshooting, and emergencies.

• The most commonly used terms align with ELSO guidelines and ECMO specialist training manuals.

• The less common terms may still be used in certain ECMO centers, among perfusionists, or in specialized discussions.

If you work in an ECMO center that uses alternative terms, it’s worth clarifying and ensuring everyone on the team understands the same terminology.

Final Thought:

Whether you’re new to ECMO or a seasoned specialist, having a clear grasp of ECMO circuit terminology ensures effective collaboration and patient safety. If you’re ever unsure, ask for clarification—communication is just as important as technical skills in ECMO care!

Learn more

For a deeper dive into becoming an ECMO Specialist, sign up for this free website: ECMO 143: AI-Assisted Journey.

I built a Custom GPT, AI ECMO Educator. It is free to use and provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on sources like ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

Over several recent ECMO orientation shifts, I was reminded of how much the role changes when you are helping someone else orient.

At the beginning, I stay close to the center of the action. I demonstrate procedures, explain decisions, and guide things step by step.

As the orientee gains experience, that starts to shift. I step back more. They lead the workflow, and I watch the patient and the circuit. Eventually, my role becomes supervision. They do the work, and I become the safety net. That part takes discipline. The natural urge is to jump in and do it yourself. Good orientation means resisting that urge while still keeping the patient safe.

In this case, the orientees were already experienced ICU nurses, and over several shifts, it was easy to see their confidence grow. What I appreciate about ECMO orientation is that it often becomes shared discovery. They asked good questions, and not every answer was obvious. That gave us a chance to pause, look things up, and learn together.

I’ve been fortunate to work with physicians, nurses, and ECMO specialists who take time to teach. Being on the receiving end of that makes it easier to pass something along. In critical care, the goal is not to know everything. It is to protect the patient, stay curious, and keep learning. Some of those questions also led us back to the lab signs of hemolysis in ECMO patients, which I wrote more about in “Hemolysis on ECMO: What It Means at the Bedside.”

Learn more

For a deeper dive into becoming an ECMO Specialist, visit my website: ECMO 143: AI-Assisted Journey.

I built a Custom GPT, AI ECMO Educator. It is free to use and provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on sources like ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

To understand how blood moves through the heart, we can number the valves in the order in which the blood passes through them as it travels from the venous to the pulmonary and then to the arterial side.

The Sequential Order of Heart Valves

1. Tricuspid Valve: The first valve. It allows deoxygenated blood to flow from the Right Atrium into the Right Ventricle. Tri=3 leaflets for the valve

2. Pulmonary Valve: The second valve in the sequence. It opens to allow blood to be pumped from the Right Ventricle into the Pulmonary Artery on its way to the lungs. There are 3 leaflets for the pulmonary valve.

3. Mitral Valve (also called the Bicuspid Valve): After the blood is oxygenated in the lungs, it returns to the Left Atrium and passes through this third valve into the Left Ventricle. Bi (cuspid) = 2 leaflets for the valve.

4. Aortic Valve: The final valve. It opens to allow oxygen-rich blood to leave the Left Ventricle and enter the Aorta, which distributes it to the rest of the body. 3 leaflets for the aortic valve.

Two Quick Memory Tricks

Here are a few solid memory tricks to help you remember the right-to-left valve sequence

(Tricuspid → Pulmonary → Mitral → Aortic):

Bonus Valve Information

The Rule of Three

3 valves have 3 leaflets:

• Tricuspid

• Pulmonary

• Aortic

This design allows a wide opening for flow and tight closure under pressure.

The Mitral Exception

The Mitral valve has 2 leaflets.

It sits on the left side of the heart and handles the highest pressures (transvalvular).

It is supported by chordae tendineae and papillary muscles, which prevent it from prolapsing back into the left atrium.

Why This Matters at the Bedside

If you understand the sequence, you can troubleshoot faster.

Example:

• Pulmonary edema? Think Mitral or left side problem

• High CVP and congestion? Think Tricuspid or right side problem

• No pulse pressure on VA ECMO? Think Aortic valve not opening

Start with flow. Then find where it’s blocked or leaking.

Learn more

If you want more ECMO breakdowns like this, make sure you are subscribed to this newsletter, ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator, an evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Sources include ELSO, PubMed, AmSECT, and leading centers. Version 5.2 (2/21/26) | Supports 50+ languages.

Both nursing and respiratory therapy backgrounds provide distinct, highly valuable skill sets that uniquely prepare clinicians for the role of an ECMO Specialist. While both professions work in high-stakes critical care environments, they approach the therapy from different foundational strengths.

The Nurse’s Advantage: Holistic Patient Management. Critical care nurses excel at comprehensive patient management and bring a distinct advantage in treating the body as a whole system. Their unique contributions include:

• Holistic Assessment: Nurses are trained to perform thorough head-to-toe assessments, allowing them to notice subtle changes, such as decreased urine output, mottling, or pupillary asymmetry, that may indicate underlying circuit or perfusion issues.

• Complex Pharmacology: ECMO patients require careful combinations of sedatives, paralytics, vasopressors, and anticoagulants. Nurses already understand how these complex medications interact, how to safely titrate them, and how to monitor for side effects.

• Line and Wound Care: Nurses are highly experienced with invasive lines (central lines, arterial lines, chest tubes) and sterile techniques. This translates directly to monitoring ECMO cannulas, securing sites, preventing infection, and managing localized bleeding.

• Hemodynamic Management: Nurses, particularly those from cardiac ICUs, are adept at walking the tightrope of balancing blood pressure and perfusion, which is crucial when managing circuit flow alongside a patient’s native cardiac function.

• Care Plan Execution and Family Communication: Nurses are experts at integrating the multidisciplinary care plan, including nutrition, skin care, and mobility, and serve as a crucial, compassionate bridge for families who are overwhelmed by the ECMO machinery.

The Respiratory Therapist’s Edge: Mastering the Mechanics. Respiratory therapists (RTs) bring an unparalleled expertise in gas exchange and cardiopulmonary mechanics, which form the core of what ECMO actually does. Their unique contributions include:

• Gas Exchange and ABG Mastery: RTs deal with gas exchange physiology daily. They can swiftly interpret arterial blood gas (ABG) panels, including pre-oxygenator and post-oxygenator gases, and immediately determine the appropriate interventions.

• Sweep Gas Management: The tasks of adjusting sweep gas to clear carbon dioxide and adjusting FiO₂ to optimize oxygenation mirror what RTs already do with mechanical ventilators. This gives them a major head start in manipulating the ECMO circuit’s artificial lung.

• Mechanical Ventilation and ECMO Integration: In VV ECMO, the goal is often to “rest” the lungs. RTs are uniquely skilled at balancing extracorporeal support and protective mechanical ventilation (e.g., low tidal volumes or minimal PEEP) to prevent lung trauma.

• Oxygenator Troubleshooting: When a patient desaturates, RTs naturally follow a methodical sequence to diagnose the issue (e.g., checking gas flow, FiO₂, or looking for clotting), mirroring how they troubleshoot a deteriorating patient on a ventilator.

Ultimately, becoming an ECMO specialist requires both professions to bridge their knowledge gaps. Nurses must deepen their understanding of circuit physics and advanced gas exchange, while RTs must expand their scope to encompass total-body hemodynamics, broad-spectrum pharmacology, and comprehensive patient care.

Learn more

If you want more ECMO breakdowns like this, subscribe to this newsletter, ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator.
An evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting.
Sources include ELSO, PubMed, AmSECT, and leading centers. Version 5.2 (2/21/26) | Supports 50+ languages.

I understood the basics of hemolysis on ECMO. Watch for rising plasma-free hemoglobin, clots, and high negative inlet pressures.

What I had not fully worked through were the consequences. How free hemoglobin contributes to kidney injury, vasoconstriction, and oxidative stress. Or how to interpret labs like haptoglobin in a meaningful way.

So I did an AI-assisted deep dive and turned it into a practical breakdown for the bedside.

What is hemolysis?

Hemolysis is the destruction of red blood cells. On ECMO, it usually means the circuit is stressing the blood due to suction, turbulence, or clot.

When red blood cells rupture, hemoglobin is released into the plasma. This is intravascular hemolysis.

A small amount of hemolysis can occur even in a normal circuit. The concern is when it increases or begins trending upward.

Why it matters

Hemolysis is often the first warning that the ECMO circuit is developing a mechanical problem.

On ECMO, hemolysis is usually circuit-related, not just patient-related. It can point to high shear stress, very negative drainage pressure, suction events, fibrin deposition, pump thrombosis, or oxygenator clot burden before the situation becomes a full circuit emergency.

Free hemoglobin is directly harmful.

Once hemoglobin is released into plasma, it is no longer contained. Free hemoglobin, heme, and free iron contribute to oxidative injury, deplete nitric oxide, promote vasoconstriction, and can lead to renal tubular injury and abnormal coagulation. This can progress to organ dysfunction.

Hemolysis also reduces effective oxygen delivery.

Red blood cell destruction contributes to anemia, but more importantly, rising plasma-free hemoglobin is associated with worse clinical outcomes during ECLS. It reflects both a blood problem and a system problem.

How to recognize hemolysis on ECMO

No single lab confirms hemolysis on its own. You need a pattern and a trend.

The most important question is not “is this abnormal?” but “is this getting worse?”

What to look for

Strongest indicator:

Plasma-free hemoglobin (pfHb)

This is the principal biomarker for intravascular hemolysis.

• <10 mg/dL: Normal

• 10-50 mg/dL: abnormal in some studies

• >50 mg/dL: widely used threshold for significant hemolysis

• 100 mg/dL: severe and should prompt immediate action

A rising trend is the most important signal

Supportive indicators:

These support the diagnosis but are not specific on their own.

Lactate Dehydrogenase (LDH)

LDH is released when cells break down.

It supports the diagnosis of hemolysis, but it is not specific. LDH also rises in shock, liver injury, and tissue damage.

Use LDH as a supporting signal, not a primary one.

Haptoglobin

Haptoglobin binds free hemoglobin.

When hemolysis occurs, haptoglobin is consumed and levels fall.

Low or undetectable haptoglobin supports hemolysis, but it is unreliable in critically ill patients. Many ECMO patients already have low levels at baseline.

Think of it as supportive evidence only.

Bilirubin

Indirect bilirubin may rise as hemoglobin is broken down.

This is a slower marker and not specific. It helps support the overall picture but should not drive decisions on its own.

Hemoglobin (Hb)

A falling hemoglobin can suggest hemolysis, but it is not specific.

On ECMO, hemoglobin can drop for several reasons: bleeding, dilution, or lab draws.

If hemoglobin is falling and plasma-free hemoglobin is rising, that combination is more concerning.

Hemoglobinuria

Pink, red, or tea-colored urine can suggest hemoglobinuria.

This is a useful bedside clue but not diagnostic on its own.

Falling hemoglobin without bleeding

Suggests red cell destruction but requires context.

Circuit clues

These increase suspicion for circuit-related hemolysis:

• Very negative drainage pressure

• Suction events or chatter

• Rising transmembrane pressure (>60 mmHg)

• Fibrin deposition or visible clot

• Worsening oxygenator gas transfer

Why hemolysis happens

Most causes fall into three categories:

1. Drainage problems

• High negative inlet pressure

• Suction events

• Hypovolemia

• Cannula malposition

2. Flow and shear

• High RPM

• Excessive flow for cannula size

• Turbulent flow

3. Circuit or device issues

• Oxygenator clot or fibrin buildup

• Pump head thrombosis

• Tubing kinks or obstruction

4. Other mechanical support devices

Hemolysis is not limited to ECMO.

Devices like Impella can also contribute due to shear stress, especially with high support levels, suction events, or malposition.

In patients on combined support (ECMO + Impella), both systems should be evaluated.

What to do at the bedside

Start with one question:

Why is this circuit or device damaging blood?

1. Assume the circuit until proven otherwise

Review pump flow, RPM, drainage pressures, and recent suction events.

Hemolysis worsens with high flow, high shear, poor preload, and unstable drainage.

2. Inspect the circuit

Use a bright light. Look at the oxygenator and tubing for fibrin or clot.

If there is visible clot, rising pressures, or worsening gas exchange, treat that as part of the problem.

3. Reduce contributing forces

• Improve preload if appropriate

• Minimize suction events

• Reduce excessive flow or RPM

• Stabilize drainage conditions

4. Escalate early if the trend is worsening

If hemolysis is severe, rising, or associated with thrombosis:

• Consider oxygenator exchange

• Consider full circuit exchange

5. Evaluate other devices

If present:

• Check Impella position

• Reduce support level if appropriate

• Address suction or malposition

6. Monitor the patient closely

Follow:

• Plasma-free hemoglobin

• Kidney function

• Urine color

• Hemoglobin trend

• LDH and bilirubin

Hemolysis can quickly shift from a circuit issue to a patient injury issue.

The bedside framework

When plasma-free hemoglobin is rising, narrow it down:

• Too little drainage

• Too much shear

• Or clot forming

Most problems fall into one of these three.

Final thought

Hemolysis is one of the clearest signals that the ECMO circuit or support device may be harming the patient.

If plasma-free hemoglobin is rising, something is wrong.

Find it early. Fix it early.

Learn more

If you want more ECMO breakdowns like this, subscribe to ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator.
An evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting.
Sources include ELSO, PubMed, AmSECT, and leading centers.
Version 5.2 (2/21/26) | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

This year, I’m opening the ECMO 143 Newsletter to guest contributors. I’ll still be writing regularly, but now I want to feature voices from across the field: specialists, nurses, RTs, perfusionists, physicians, educators... anyone involved in ECMO or mechanical circulatory support who has something useful to share.

What can you write about?

If you’ve learned something, built something, want to explain a concept, or tried something that made a difference, this is your invite to write. You don’t need to be an expert, and your draft doesn’t have to be perfect. You just need a clear point and a willingness to share it. I’ll help shape it from there.

The focus remains ECMO, but I’m also open to related mechanical support, such as Impella, IABP, or VADs. Case studies, troubleshooting tips, training workflows, bedside insights, protocol reflections: anything practical, grounded, and clinically useful. It can be something that interests you, and it does not have to be complicated.

Here is how it works

Articles should be around 600 to 1,000 words—enough for a solid 3- to 5-minute read. If you want to contribute, DM me. You can send a rough draft or just a few notes. I’ll help edit for clarity, format it for the ECMO 143 newsletter, and send it back to you for approval. Nothing gets published without your final sign-off, and you’ll be listed as the author. My role is to help you shape it and make it clean. Your role is to bring your real-world experience to the table and help others learn.

Let’s grow this together. Jon

TLDR

• Interviews with 9 ECMO nurses in Colombia.

• Training varied a lot across settings, so readiness varied too.

• Supervised practice and simulation built confidence more than lectures.

• Nurses saw competence as technical skill plus stress control and communication.

The setup

This study didn’t measure patient outcomes. It asked nurses to describe the training process in their own words.

Study snapshot

• Location: Colombia, South America

• Participants: 9 nurses involved in ECMO care

• Approach: Qualitative interviews (experience-focused)

What nurses said, in plain terms

1. The pathway isn’t consistent. Some nurses described formal education routes. Many described local, institution-built training. When programs expanded fast (especially during COVID), onboarding could get compressed. The result was uneven preparation. In ECMO, uneven preparation shows up when the first real crisis becomes the first real learning moment.

2. The theory foundation can be thin. Nurses described a gap between the complexity of ECMO and how much structured teaching they received up front. Many tried to fill that with self-study. That helps, but it also creates variability. Two nurses can “self-study” and end up with two very different mental models.

3. Resources aren’t automatically usable. Being handed a reference is not the same as being taught. Nurses described barriers like dense material and language limitations. When learning materials feel out of reach, people shift toward shortcuts: memorized steps, copied notes, or partial understanding. That works until the case deviates from the script.

4. Mentorship and reps are what change confidence. Nurses valued supervised bedside time with experts. They described how coaching helped them connect the why to the what, and how psychological safety mattered. If a nurse can ask questions early and often, they build pattern recognition faster and make fewer silent mistakes.

5. Simulation mattered when patient exposure was limited. Nurses who had meaningful simulation described feeling more prepared when real problems occurred. Simulation gave them a safe place to practice recognition, communication, and response structure. It reduced panic. It helped them show up calmer when the room got chaotic.

6. Competence includes the human part of the job. Nurses described fear, insecurity, and emotional load, especially early on and during complications. They also described the pressure of team coordination and family communication. They saw these as real skills that training should address, not optional extras.

What this suggests for training programs

Standardize what “ready” means across sites and preceptors. Build a progression that includes supervised bedside reps and simulation before independent coverage. Make learning materials accessible and usable for the actual learners. Assess competence in a way that reflects real performance, not just completion.

Summary

In Colombia, nine ECMO nurses described training as uneven and often too dependent on local resources and timing. They emphasized supervised practice, strong mentorship, and simulation as the fastest route to real readiness. They also made it clear that safe ECMO care requires more than technical competence. It requires stress control, clear communication, and steady team function when things go wrong.

Your Turn

How does your unit currently train nurses and RTs for ECMO?

1. What’s non-negotiable before someone takes independent coverage?

2. How do you use simulation (if you do)?

3. What’s the biggest gap you still see in new ECMO specialists?

If this was useful, hit Like so more ECMO folks see it. If you want more posts like this, make sure you’re subscribed to this newsletter.

I also offer a free, additional newsletter for Families + ECMO patients: ecmo.life

Complete reference (open access)

Madariaga M, Moreno F, Vergel J. Nurses’ Experiences in the ECMO Training Process: A Qualitative Study. Revista Cuidarte. 2025;16(3):e4605. doi:10.15649/cuidarte.4605. Open access.

If you’re reading this from an ICU waiting room, you’re doing something hard. You showed up. You stayed. That matters.

Today might not look like Christmas. The day can feel slow, loud, confusing, and unfair. Machines beep. Plans change. Updates come in pieces. You may feel calm one minute and wrecked the next. That’s normal.

Here’s what I hope you remember today:

1. Your presence helps, even when you don’t know what to say.

2. It’s okay to take breaks. Eating, sleeping, and stepping outside are part of staying strong.

3. You don’t need to understand every number on the screen to be a good advocate.

If you want something practical to do today, try this:
Ask the bedside nurse or provider these three questions:

1. What are the main goals for the next 24 hours?

2. What would make today a “good day” medically?

3. What signs would mean we’re moving in the right direction?

Then write the answers down. It helps when you’re tired. It also helps when different family members rotate in.

If your loved one is awake, even a little, simple is best:
“I’m here. You’re safe. We’re taking it one step at a time.”

If your loved one is sedated, talk anyway. Familiar voices can still matter:
“It’s Christmas. I love you. I’m staying close.”

And if you’re carrying guilt, fear, or anger today, you don’t need to fix it in one sitting. Just get through the next hour. Then the next.

Merry Christ mas. You’re not failing because this is hard. This is hard because it matters.

When your patient gets cold, hemoglobin holds onto oxygen tighter. Cooling shifts the oxyhemoglobin curve to the left, so at a given PaO2, you may see a higher SaO2, but less oxygen gets unloaded to the tissues. On ECMO, that means the “numbers” can look reassuring while perfusion and tissue oxygenation are not. If you’re fighting hypothermia, it’s worth thinking beyond the saturation and watching the whole picture: temperature, lactate trend, perfusion, and venous oxygen data if you have it.

Merry Christ-mas

Jeffrey Scott, DO, MBA, FASE, one of the guest editors of this newsletter, recently told me about “Echo In Cardiac Mechanical Support,” an online course which he helped create. It is a new online course from the American Society of Echocardiography. ASE added this video to its educational site that covers echocardiography and critical care ultrasound for mechanical support, including VA and VV ECMO, intra-aortic balloon pumps, and left ventricular assist devices. Developed by an international team of intensivists specializing in cardiothoracic ICU care, the course costs $85.00 and offers about 4 hours of CME credit.

• Cardiac stun is a reversible myocardial dysfunction. The heart is alive but temporarily unable to contract.

• It shows up on VA-ECMO as low EF, no pulsatility, poor MAP, and rising lactate.

• It happens because of ischemia–reperfusion, severe hypoxia, prolonged shock, and sudden afterload spikes when starting VA flows too fast.

• Cold prime and metabolic instability can worsen the picture — the problem isn’t Plasmalyte, it’s temperature and how fast I increase the ECMO flow.

• You resolve it by slow-controlled ECMO initiation, correcting metabolic problems, supporting perfusion, and letting the myocardium recover.

• The heart isn’t dead. It just needs time. ECMO gives it that time.

A few days ago, someone asked me a simple question:

“Hey Jon, what exactly is cardiac stun?”

I knew the usual bedside signs — weak squeeze, low stroke volume, almost no pulse pressure, lactate creeping up even with “good” circuit flow. But when I tried to give a clear, confident explanation, I realized I was only describing what it looks like, not what it is or why it happens.

So I went back, reviewed the physiology, double-checked the ECMO guidance, and asked my AI ECMO Educator GPT to help me tighten the concept. What came out is the version I wish I had ready in the moment, and the version I think early ECMO clinicians deserve: something practical, accurate, and actually usable at the bedside.

Here it is.

1. What Cardiac Stun Is

Cardiac stun is a temporary myocardial dysfunction after a major physiologic insult.
The myocardium is alive and well-perfused, but the muscle can’t generate an effective squeeze. It’s not infarction, it’s not permanent damage — it’s a ventricle recovering from shock, hypoxia, or reperfusion.

On VA-ECMO, it typically looks like:

• Very low EF on echo

• Minimal or absent pulsatility on the arterial line

• Tiny stroke volume, even with full coronary perfusion

• MAPs are completely dependent on ECMO flow and vasoactive support

• Lactate that rises or clears slowly because forward flow is insufficient

The key idea:
The heart has oxygen. It has perfusion. It just doesn’t have the contractile strength yet.

ECMO doesn’t fix the heart — it carries the circulation while the heart repairs itself.

2. Why Cardiac Stun Happens

Several pathways lead to cardiac stun, and most ICU clinicians have seen at least one of them. The physiology is straightforward once you look at the sequence.

Ischemia–Reperfusion After Arrest

After downtime, the heart gets blood flow back — but the myocytes aren’t ready to contract. They need time to recover, redistribute calcium, normalize pH, and restore ATP levels.

Severe Hypoxia or Prolonged Shock

A ventricle exposed to prolonged underperfusion loses contractile reserve. Even after restoring oxygen delivery, mechanical output lags behind.

Abrupt Hemodynamic Shifts During VA-ECMO Initiation

This one is under-taught but very real:

When you start VA flows too fast, you instantly increase LV afterload.
A stunned or borderline heart may not be able to open the aortic valve against that pressure.

The result is:

• No pulsatility

• No forward stroke volume

• A ventricle that looks even worse after ECMO is started

This isn’t ECMO “hurting” the heart — it’s ECMO exposing how little native output was left.

Systemic Inflammation and Vasoplegia

Post-arrest and septic physiology depress contractility globally. ECMO restores perfusion, but it doesn’t instantly reverse the inflammatory myocardial depression.

What About the Prime? (The Accurate Version)

I’ve heard (and once believed) the idea that:

“Plasmalyte doesn’t carry oxygen, so it can stun the heart if you start VA too fast.”

Here’s the fact-checked version:

• Crystalloid prime doesn’t carry oxygen, but it mixes immediately with circulating blood.

• The heart is not perfused with pure crystalloid in isolation.

• ELSO does not list crystalloid prime as a cause of stunning.

The real factors are:

• Cold prime: can transiently depress myocardial function

• Rapid flow initiation: spikes afterload

• Metabolic instability: acidosis, hypothermia, low calcium

So the teaching point is this:

Temperature and how fast you increase your ECMO flow matter far more than whether the prime is Plasmalyte.

3. How Cardiac Stun Resolves

You can’t “treat” stun directly — the myocardium simply needs time to recover. But you can create the conditions for recovery.

Controlled Flow Initiation

Start VA-ECMO gradually. Build flow slowly, allowing the LV to adjust and preventing an abrupt afterload hit.

Correct Metabolic Problems

The stunned ventricle won’t recover if the environment is hostile:

• Normalize calcium

• Correct acidosis

• Maintain temperature

• Optimize electrolytes

Many centers give calcium at initiation for this reason.

Support Perfusion

While the heart rests:

• Maintain appropriate ECMO flow

• Use vasoactive support judiciously

• Monitor lactate and regional perfusion

• Avoid unnecessary LV distention

Unload the LV When Needed

If the aortic valve isn’t opening and the LV begins to distend, intervene early:

• Reduce afterload

• Consider inotropes, IABP, Impella, or surgical venting, depending on your program

Watch for Signs of Recovery

You’ll know the heart is coming back online when you see:

• The aortic valve opens intermittently

• Pulse pressure returning

• Stroke volume rising

• Improved lactate clearance

Once you see pulsatility, the heart is re-engaging.

Closing Thoughts

Cardiac stun used to feel vague to me — something people mentioned, assumed, and moved past without a clear explanation. Being asked directly forced me to clarify what it actually is and why it shows up the way it does, especially during VA-ECMO initiation.

Here’s where I landed:

Cardiac stun is the myocardium saying, “I’m viable — I just need time.”
Our job is to protect the patient while the heart rebuilds its ability to generate mechanical work.

VA-ECMO gives the heart the chance to recover, and when it does, it’s unmistakable:
Pulsatility returns, the aortic valve opens, and the circulation begins to shift back toward native output.

That moment never gets old.

The final two days of the ECMO Diploma Course were a solid mix of lectures and practical discussion. I picked up new ways to approach problems and left with a clearer understanding of how other centers manage similar cases. The class participation added just as much value as the lectures, sometimes more.

We had a strong international mix in the room, with representatives from India, Egypt, the U.S., New Zealand, Australia, Peru, and Eastern Europe. That diversity made the conversations richer and more grounded. Everyone brought something real to the table—different approaches, different system limitations, different habits, same pressure to do the right thing.

Topics covered on June 25:

• My patient remains hypoxemic on VV-ECMO (C.-E. Luyt)

• Neurologic complications of ECMO (C.-E. Luyt)

• COVID cardiac involvement (G. Hekimian)

• La Pitié experience of ECMO for COVID (M. Schmidt)

• Management of anticoagulation in ECMO patients (M. Schmidt)

• Bleeding on ECMO: causes and management (C.-E. Luyt)

• Infectious complications of ECMO (M. Schmidt)

• Tutorial: how to wean patients from VV-ECMO? (M. Schmidt)

• ECMO for refractory cardiac arrest, in-hospital, out-of-hospital, E-CPR results (A. Combes)

• Discussions of concrete cases at the bedside

Topics covered on June 26:

• Ethical aspects of ECMO (C.-E. Luyt)

• Long-term outcomes after ECMO (C.-E. Luyt)

• Indications and results of ECCO2R techniques (A. Combes)

• Fulminant myocarditis: diagnosis, outcomes, and results of ECMO (A. Combes)

• ECMO and immunocompromised patients (C.-E. Luyt)

• Intoxication with cardiotoxic drugs: indications and results of ECMO (G. Hekimian)

• Tutorial: how to wean patients from VA-ECMO (G. Hekimian)

• Circulatory assistance with the IMPELLA device (A. Combes)

We wrapped up with a short diploma ceremony. Alan Combes handed out the certificates with his usual calm and understated style. It was a good way to close—simple, meaningful, and appreciated.

Also worth mentioning: the food was excellent. Possibly too excellent. I’m just hoping Delta doesn’t charge me for the extra weight I’m bringing home, or flag me for a seat belt extension.

I highly recommend the course, which is offered several times per year. Full details here:

https://ecmo-courses.paris-ecostcs.com

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

ECMO 143: Projects and Tools

As part of ECMO 143, I’ve developed these resources to support both professionals and families in the ECMO space:

• lifesupport.training – Resources for ECMO and other professionals,

• ecmo.life – Information for ECMO patients and their loved ones

• YouTube: ECMO 143 – Occasional AI-supported podcasts

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs available on OpenAI:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology

At ECOS-TCS 2025 in Paris, I had the chance to see Getinge’s CardioHelp 2 in person and speak directly with one of their reps. Below is a quick summary of what’s actually different from the original.

What’s New

Redesigned Interface
A larger touchscreen with an intuitive layout and guided workflows for setup, troubleshooting, and operation.

Integrated Gas Blender
Now built into the system—no more external blender needed, even during transport.

Weight Reduction
The unit is over 25% lighter than the original. Carbon fiber components help reduce weight while keeping it durable.

SvO₂ Probe Update
Still locked to the machine, but now redesigned to improve reliability and reduce probe failure—this was a known issue with the original.

NIRS Integration
CardioHelp 2 is designed to support near-infrared spectroscopy (NIRS) for cerebral and somatic oxygenation monitoring.

Other Specs

• Weight: ~12 kg (26 lbs)

• Dimensions: 255 x 315 x 427 mm

• Battery life: 90+ minutes

• Flow: Up to 8 LPM with HLS sets

• Supports VV and VA ECMO

• Not yet FDA approved (expected mid-2025)

Final Notes

I filmed a short video at the booth showing the new system.

More details are available at Getinge’s official site: getinge.com/int/campaigns/cardiohelp-2

Let me know if your team is planning to upgrade or stick with the original.

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

ECMO 143: Projects and Tools

As part of ECMO 143, I’ve developed these resources to support both professionals and families in the ECMO space:

• lifesupport.training – Resources for ECMO and other professionals,

• ecmo.life – Information for ECMO patients and their loved ones

• YouTube: ECMO 143 – Occasional AI-supported podcasts

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs available on OpenAI:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology.