Advanced therapy gives a lifeline to the sickest of COVID patients

By Ana Fernandes

Over two months have passed and that piece of paper still lies on her coffee table, with four letters on it: “ECMO.” Irena Veronese had never heard that acronym before, but when it was first mentioned to her, it meant moving from complete despair to a shred of hope of saving her husband’s life.

The treatment called Extracorporeal Membrane Oxygenation (ECMO) consists of a machine that oxygenates the blood outside the body. It is normally used for transplant patients or patients with severe heart or lung disease.

During this pandemic, it has also been used as a last resort to save some of the sickest COVID-19 patients at Toronto General Hospital, part of the University Health Network (UHN).

Mladen Veronese turned 54 years old on April 1, the same day that he was taken to hospital. He had no pre-existing conditions, but was one of the cases where COVID symptoms got very bad, very fast.

Mladen has barely any recollection of that day, but when he arrived at St. Michaels Hospital on his birthday, his breathing had deteriorated to a point that he couldn’t finish a sentence. He needed support from mechanical ventilation.

Irena and their 18-year-old son were back at home as they couldn’t accompany Mladen, because of isolation measures in place at the hospitals. Irena says it was all very sudden, and somewhat unreal.

“We were getting calls from family and loved ones who wanted to congratulate him for his birthday, and we had to tell them that Mladen was taken to hospital,” Irena explains.

“We were anxious but also hopeful that he was getting help. I don’t think we realized back then how serious it would get.”

Preparing for the worst

Mladen Veronese (left) is one of many patients who survived COVID-19 after being treated with a heart-lung bypass machine at UHN.

Three days later, Irena recalls getting one of the worst phone calls of her life. Her husband’s care team contacted her to say Mladen’s condition was deteriorating very quickly. His ventilator was on the maximum setting, he was in an induced coma and in the prone position (laying on his stomach) for best possible oxygenation, and yet he was not responding.

“It was a very difficult call. It felt like they were preparing me for the worst,” she says.

About 10 minutes later, Irena got another call with a message of hope. Her husband had been accepted for the ECMO program, which is led by members of the Critical Care Medicine, Sprott Department of Surgery and the Ajmera Transplant Centre at UHN.

“It was an emotional roller coaster. We went from the lowest point to believing a miracle was possible.”

Irena quickly jotted down on a piece of paper that four-letter acronym so she could google it after. But as the doctors explained this was the only option to try to save Mladen, she consented and held on to that shred of hope.

Learning with the pandemic

When reports about the severity of COVID-19 in Asia started to rise, in the beginning of the year, the ECMO teams at UHN mobilized quickly. The program was able to get not only more ECMO machines, but more drugs and personal protective equipment (PPE) in a time of international shortage.

“Our team was very creative in finding quick solutions to keep everyone safe while also delivering the best possible care to our patients,” says Maria Kobylecky, Advanced Practice Nurse Educator at the Medical Surgical Intensive Care Unit (MSICU).

Nursing teams looked for example at placing infusion pumps outside of the room and adapting models of care to minimize exposure for staff. They redesigned the unit to add more beds and also trained staff from other programs so they could support the ECMO teams.

“It was still overwhelming to see how many COVID patients came in severely ill and requiring long hospital stays, but we felt more prepared because all this work was done ahead of time,” says Lourdes Calanza, a Registered Nurse at the MSICU.

A tremendous team effort

Mladen Veronese was one of many patients with COVID-19 treated with ECMO at UHN. Even as the pandemic slows down, severely ill patients are still being admitted to the program, and as young as 20 years old.

“The patients referred to us during this pandemic are the sickest of the sick, and who probably wouldn’t have a chance if it wasn’t for this treatment,” says Dr. Eddy Fan, Medical Director of UHN’s Extracorporeal Life Support Program.

So far, 32 COVID-19 patients have been treated with ECMO at UHN, with an average survival rate of 65%. This means giving a real fighting chance for patients who are on the brink of death.

“We have the largest and most comprehensive ECMO centre in Canada and we provide the highest quality of care to our patients. This success is the result of a tremendous team effort,” says Dr. Marcelo Cypel, Surgical Director of UHN’s Extracorporeal Life Support Program.

Every patient is looked after by a team of physicians, surgeons, nurses, perfusionists, respiratory therapists, physiotherapists, speech therapists, dietitians, pharmacists, patient care assistants, social workers, spiritual care professionals, and more.

“We’re very proud to be able to provide this level of care,” says Dr. Cypel.

Risk factors

Using this machine that works as artificial lungs also comes with risks. That is why there are some criteria to recommend this therapy. For COVID-19, for example, it is recommended for patients who aren’t responding to ventilation, who develop symptoms rapidly, who are under 65 years old and who don’t have certain pre-existing conditions.

Mladen says he’s not sure if he’s unlucky for getting so sick with COVID or lucky for getting access to ECMO and having this second chance on life. His wife Irena quickly responds: “You are extremely lucky.”

“We didn’t think Mladen would make it. And I think that’s the main reason I can’t throw that tiny piece of paper away. Those four letters ‘ECMO’ represent everybody involved in his care and the incredible journey to save him.”

Although Mladen can’t remember much, as he was sedated during three weeks while being treated with mechanical ventilation and ECMO, he is extremely grateful to all his care teams across St. Michael’s, UHN and Bridgepoint hospitals – this last one where he had his rehabilitation care.

After a very turbulent birthday in April, he now is planning a special celebration with his wife for their 25th wedding anniversary, on July 2nd.

Ana Fernandes works in communications at University Health Network.