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At Scripps La Jolla, ECMO patients bear silent witness as pandemic hits one-year mark

At Scripps Memorial Hospital La Jolla, a COVID-19 patient is treated with ECMO (extracorporeal membrane oxygenation).
At Scripps Memorial Hospital La Jolla, a COVID-19 patient is treated with an ECMO (extracorporeal membrane oxygenation) machine.
(Nelvin C. Cepeda / The San Diego Union-Tribune)

While overall COVID-19 numbers decline, hospitals continue to treat the most severely affected.

As the first anniversary of the COVID-19 pandemic arrives, the understanding of what’s possible when caring for patients with severe respiratory illness has been reset.

When San Diego County’s first COVID-19 patient began showing symptoms on Feb. 14, 2020 — the day the county declared a public health emergency due to the coming pandemic — nobody could have imagined how much the health system would eventually have to stretch to meet the demands of a disease capable of quickly stealing a person’s breath.

Though the overall number of COVID-19 patients in hospital beds has been shrinking, the high-water mark set by the recent surge is still visible among the sickest of the sick.

They are the people whose respiratory failure was too acute to be helped by even the significant improvements in treatment ranging from drugs like steroids to turning patients regularly to help their lungs function.

These are the patients whose caregivers were forced to shunt their entire blood supplies through a special machine capable of adding oxygen and removing carbon dioxide after their lungs surrender to the out-of-control inflammation that has become the disease’s harrowing hallmark.

A patient on ECMO
A COVID-19 patient at Scripps Memorial Hospital La Jolla is on ECMO (extracorporeal membrane oxygenation), in which one line is where the patient’s blood is drawn into the ECMO pump and the second line is where the blood is returned to the patient.
(Nelvin C. Cepeda / The San Diego Union-Tribune)

That technique, called extracorporeal membrane oxygenation, or ECMO, is labor-intensive and extremely high-risk, increasing the danger for blood clots, brain bleeds and stroke even as it offers a coin’s flip chance of survival.

Juliann Eigner, a critical-care cardiac nurse and manager of the acute mechanical circulatory support program at Scripps Memorial Hospital La Jolla, said COVID-19 has overrun all reasonable expectations.

“With the H1N1 pandemic a decade ago, if we had four patients on ECMO at one time we thought that was a lot,” Eigner said. “Now we consistently have between eight and 10 patients on service at Scripps alone.”

Across the region, there were 26 ECMO patients in San Diego-area hospitals Feb. 12, six more than the number previously considered the collective maximum regional capacity. Demand has been so strong since last spring that local hospitals with staffs trained to provide the ECMO service formed a consortium, drawing together UC San Diego, Scripps and Sharp HealthCare to train more workers and increase the region’s overall capacity to 31 simultaneous patients.

A COVID-19 patient receives ECMO treatment at Scripps Memorial Hospital La Jolla.
(Nelvin C. Cepeda / The San Diego Union-Tribune)

In a pandemic that has produced more than 250,000 cases and more than 3,000 deaths in San Diego County, 31 might not seem like that many.

But ECMO, because it requires an extra layer of medications and monitoring beyond what would normally be required for an intensive care patient on a ventilator, demands many more hours of labor.

And ECMO patients may spend months on the service as a broad team of specialists, from pulmonologists to physical therapists, works first to help the body adjust to the fact that breathing is no longer necessary and then to the need to start breathing again when it is time to withdraw the service.

“Everyone is stretching now beyond what we were ever able to do before, and we have only been able to do that because of the shared effort, where we’re backing each other up,” Eigner said.

For many months, visitation restrictions have largely kept families from helping their loved ones navigate the process, forcing them to experience what spouses and parents are going through over video links that, while better than nothing, are no substitute for being there in person.

That appears to be changing a bit as 2021 gets under way and the recent holiday surge abates.

On a recent morning at Scripps La Jolla, a woman who declined to provide her name sat double-masked and in a yellow hospital gown lovingly holding her father’s hands, trimming his fingernails as his blood continued to circulate through the ECMO machine at his side.

At Scripps Memorial Hospital La Jolla, a COVID-19 patient on ECMO is visited by a family member.
At Scripps Memorial Hospital La Jolla, a COVID-19 patient on ECMO (extracorporeal membrane oxygenation) is visited by a family member.
(Nelvin C. Cepeda / The San Diego Union-Tribune)

Though still partially sedated and unable to speak due to a hole in his throat called a tracheostomy, his daughter said his writing, and the organization of his thoughts, had begun to improve.

Seeing her father in such condition, after he was admitted in December, was a shock. But during one-hour weekly visits, the bright red tubes full of her dad’s blood have gradually become part of the ecosystem of machinery and medication lines that enter his frame from every direction, she said.

“After awhile, you kind of learn to disconnect yourself from the idea that this machine is keeping him alive and you know that the technology is allowing them to get better,” she said.

But being there in person, she said, adds a dimension that didn’t come through over frequent Zoom calls. Being there, she said, provides the feeling that she’s helping her father’s endless team of caregivers truly see the person inside that nest of beeping infusion pumps and plastic tubing.

“We want them to see a person, not a patient,” she said. “We want them to know how much he means to us.”

Dr. David McCaul, a pulmonologist who has worked through the pandemic at Scripps La Jolla, said the presence of family members visiting their loved ones in person cannot be overestimated, especially during the grueling rehabilitation phase of ECMO treatment when patients struggle to breathe again after weeks or even months under heavy sedation. Clawing one’s way back from the muscle atrophy and other problems caused by so much time in bed is more doable when a loved one is helping identify goals and providing encouragement in reaching them, McCaul said.

“Not being able to have that interaction with families, you lose so much just in terms of patient identity,” he said. “When families are able to participate in the tragedies and the successes, you’re directing that patient’s care in the way that they want it done, and that can make a big difference.

“It’s much harder to reach those goals of care when you’re at a distance.” ◆