Episode 16

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Published on:

29th Jun 2026

S6 Ep13 Christine Stead on Systems of Innovation in ECMO

Christine Stead is the CEO of ELSO: the Extracorporeal Life Support Organization. ELSO is the premier global nonprofit for ECMO and ECLS, connecting providers, researchers, and regulatory agencies across 66 countries and nearly 800 contributing centers worldwide.

Earlier this year, Dan's conversation with Thomas Preston explored trust and communication at the bedside. They discussed what it takes for a single ECMO team to function in a single room under pressure. On this Teamcast, released in collaboration with The Emergency Mind Podcast, Christine joins Dan to talk about how ELSO held the field together during COVID: a live registry built in weeks, a global capacity map, real-time coordination running patient-by-patient across time zones. Getting information out mattered more than getting it perfect, because withholding it presented a different kind of risk.

They also get into ELSO's founding philosophy, the systems-of-systems challenge in out-of-hospital cardiac arrest, and an upcoming center certification program that has been two years in the making. If you find this episode useful, the best way to support the work is to subscribe and leave a quick rating or review.

Transcript
Preston:

Welcome to the Teamcast.

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I'm Dr.

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Preston Cline, Director of the

Mission Critical Team Institute.

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Here, we discuss all things

mission critical teams.

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These are teams of four to 12 people

indigenously trained and educated who

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solve rapidly emerging complex adaptive

problem sets where the consequence of

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failure is death or catastrophic loss.

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With my colleagues and our guests,

we bring you insights from combat

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zones to emergency rooms, dedicated to

improving the success, survivability,

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and sustainability of these teams.

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We grapple with how to prepare for

future events and how to develop

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language and frameworks to transfer

critical, often unspoken, knowledge.

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Whether you're on a mission critical

team or not, we aim to bring you

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the broadest range of topics and

guests as possible to help prepare

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you to perform when it matters most.

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Thank you for joining us, and

hope you enjoy the Teamcast

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Dan: Hi, folks.

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I'm Dan Dworkis.

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Our guest this episode is Christine Stad.

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Christine is the CEO of ELSO, which

is the premier global nonprofit for

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all things related to ECMO and ECLS.

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ELSO brings together providers,

industry, and regulatory agencies and

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others to improve patient outcomes, and

it's committed to advancing scientific

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evidence and supporting its members

to achieve high-quality programs.

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Now, I was lucky enough to meet Christine

at the ELSO International Conference.

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I think I'm saying that right.

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Yeah.

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And I was super struck by the way

that she leads this organization,

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and I'm just-- I'm really excited

to have you on the podcast.

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Thank you for coming to join us.

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Christine: Thanks so much for inviting me.

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And Dan, I can't thank you enough

also for joining the ELSO conference,

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not just as an attendee, but of

course, hosting a session there.

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I think what y-your work does in Mission

Critical aligns nicely what the work

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is of anyone that's in the ACLS space.

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So thank you so much.

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Dan: Absolutely.

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So this is gonna be, I think,

I hope, really interesting.

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We've done a bunch of ECMO-related stuff

on the podcast over the last little bit.

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But one of the things that we

keep circling around to, and we've

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approached it from a bunch of angles,

how individuals on an ECMO team

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operate, how decision-making is done

in asymmetric information spaces,

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how intensive care units handle ECMO.

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But o-one of the things that keeps

surfacing is that ECMO is such a

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complicated, uh, cutting-edge still field

that it's not enough to think about how

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the individuals and the teams perform.

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We really have to think about

how the system as a whole

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enables ECMO to happen, right?

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To take a bit of a more almost ecological

standpoint that successful ECMO is an

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emergent property of a system and a group

of teams rather than necessarily the

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direct output of a bunch of individuals.

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So I was really excited, Christina, to

bring you on because I, I think what

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ELSO does is such a vital part of this

and really not an angle that we've

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ever explored before on the podcast.

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So that's my preamble groundwork for

this in terms of like the background

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of having this conversation.

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But why don't we start here?

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H-How did you get involved in this?

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What brought you to the ECMO world, and

w-why is this what you do with your time?

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Christine: Oh, that's a great question.

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I, I started my ECMO experience

actually when I was about eighteen

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years old, and that was as a student

at the University of Michigan that

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needed a job, and so I started work

in Bob Bartlett's CCLS research lab-

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Dan: Mm-hmm

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Christine: not knowing

much about what that is.

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And I did that throughout

my undergrad experience.

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One thing I will tell you just in

that there are two things that were

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important that came out for me then.

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One, Bob Bartlett was the highest standard

of a mentor I've ever had, just in terms

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of how he worked with teams and people,

but everyone was someone he had time for

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and respected, even me, knowing close to

nothing or, yeah, really close to nothing.

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He'd spend time with anybody on the

team, and so that was really amazing.

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But the other thing I noticed, again,

just collecting research samples

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in the ICU, was that when the ECMO

team was called, things got calm.

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Mm-hmm.

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Not crazy.

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They got calm.

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Like, you just felt,

"Oh, g-thank goodness.

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They're here."

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And when they entered the room,

things got really organized.

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Nobody was screaming or shouting.

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You're just going through the motions

of what you needed to do to get the

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patient on ECMO, and it just was this

Confidence inspiring experience for

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the most part, where, yeah, there

was a little bit of chaos going on.

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Things were way different in the early

'90s than they are now, and that's

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when I was doing that kind of work.

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But that was my i-

initial exposure to ECMO.

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I started as CEO at Elso really

about a week before things closed

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down in the US due to the pandemic.

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A friend of mine who had been

in the lab back with me back

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in the day was getting his PhD.

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I was getting a bachelor's at the time.

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He had asked me if I would be willing

to help Elso out a little bit, and I

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didn't really know what he had in mind.

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But I found out soon enough

they were looking for a CEO,

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which they'd never had before.

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And I thought that would be amazing.

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That would feel like a full circle moment.

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And things lined up, so with what

I was doing with my own career

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then, that, that worked out nicely.

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But boy, we did not have a lot of time for

who are you and how are-- anything like

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that with the pandemic going on, 'cause

there was a lot more demand for ECMO.

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Not initially.

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Actually, the early findings with

ECMO was that it didn't work, and

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COVID patients shouldn't have access

to ECMO 'cause it didn't work.

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So we as an organization had to change

nearly everything that we did, how we

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did that, to try to establish data and

share with people in real-time what

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was happening with these patients that

was different and learn on the fly.

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So that by the time the, I think the,

the Diamond Princess got to, to Japan

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from the Wuhan, China experience,

things got better for COVID patients.

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And we changed our registry so that

it was not no longer a let's wait

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until the case is closed, we've

got an outcome from every patient.

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We needed live data, and so we made the

registry live for the first time too.

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But we did a lot of things.

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We can get into that later, but we did

a lot of things to, uh, really change

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not just the perception, but the reality

of ECMO as applied to COVID patients.

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And so since then, things have

been fast-paced since, since then.

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But it w- my exposure with ECMO and Dr.

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Bartlett in particular really has

been this full circle moment in my

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career, where in between undergrad

and becoming the CEO, I had a

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whole lifetime and, and in doing

other things, mostly in consulting,

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but always in academic medicine

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Dan: And okay, so if you're

following this along and you're not

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as versed in the ECMO space, Dr.

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Bartlett is widely known as the father

of ECMO, and i-is one of the-- really

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championed the teams that brought it

from a lab theory to a usable practice.

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And then as, u-until his, his

passing this year or, or in twenty

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twenty-five, was like just truly

a giant in the field in terms of

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shaping the course of all of this.

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So that's a, it's a, an amazing pedigree

to come from starting and stumbling almost

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into that space and then going on to, to

lead the helm and shape the face of this.

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There's so many fun directions in there.

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I, I definitely wanna talk about

being the champion of an organization

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through times of change and chaos.

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I love the concept of the self-organizing

team that sort of makes things quieter

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in the room as you're building around

them, and the idea of pushing information

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forward with a live registry, a-all

of which are like critically important

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and like phenomenal avenues to go down.

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Before we jump down any of those paths,

can we take a really high-level view?

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If folks haven't intersected

with ELSO, what is it?

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What does it do?

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And, and I think we'll start using

that as a jumping place to get into

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some of these stories and these ideas.

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Christine: No, that's a

good place to start, Dan.

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ELSO was founded in nineteen

eighty-nine by Bob Bartlett, and

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the reason that he founded it was

there were so few people doing ECMO.

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And ECMO at that time-- So ECMO just, for

those that don't know, does the work of

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your heart and lungs outside of your body.

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That's that extracorporeal part, and the

oxygenation part is a big part of that

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name, extracorporeal membrane oxygenation.

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Bypaths had been around for some time

previously, but so had the Gibbon heart

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and lung machine, and that was developed

in nineteen fifty-three, I think, by John

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Gibbon and his wife, Mary, and they spent

twenty-some years developing this device.

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But it did what they had

envisioned, but not well.

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And what Bartlett did was really

try to make it work much better

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because the exposure to blood and

oxygen through material, that's

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where things get interesting.

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Your blood wants to clot.

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Of course, it does.

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That's how it's designed.

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How do you make it not?

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But also, how do you optimize gas

exchange in that environment too?

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And that really-- Solving that

problem so that worked well

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was Bob Bartlett's life's work.

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And so- Back in the day, there were

a lot of people thinking about this.

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Not a lot, let's say, but let's say

twenty to thirty different centers

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around the world where you had

people that were like-minded, thought

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there was an opportunity here to

make that technology work better.

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And so he would just gather them

all and invite anybody interested

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that could help to Ann Arbor,

which is where he was at the time.

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He moved to Ann Arbor from UCI,

where he had some success at UCI

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with the first neonate put on ECMO,

and he had helped Don Hill over at

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Stanford put the first adult on ECMO.

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That was nineteen seventy-one, where

one adult was successfully put on ECMO.

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So people have been working on

this, just not so successfully.

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And a neonate Bob put on in

nineteen seventy-five, which

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is Esperanza, which means hope.

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So a nurses, a nurse there adopted her.

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Her mother had abandoned her, but

they saved her life, and she still

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comes to our conferences every year.

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Wow.

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This pool of people that were working

on this were spread out throughout the

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world, Japan, Europe, US, a few centers in

Europe, and he would just invite them in.

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But it became clear early

on to a couple of things.

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You're gonna need everyone

to make advancements.

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So everybody that's doing this, he needed

everybody, and they needed each other.

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But the other piece was data

would be really important.

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So if we could just share our data, our

patient cases, what we've learned about

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them, let's just submit it all to one

place, and that became the ELSO registry.

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Now, in nineteen eighty-nine, there were

seven hundred, a little over seven hundred

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cases that were published in a study.

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That was the first real

ELSO registry report.

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And since then, it's grown quite a bit.

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I think as of this morning, it's over two

hundred and sixty thousand patient runs.

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We have centers from sixty-six

countries that participate in this now.

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Almost eight hundred centers

around the world are contributing

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their data to the ELSO registry.

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So it's grown quite a bit from

inception, but that was the early idea.

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And the other piece he wrote in his

charter, which I love, which is, "This

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society is going to be exclusive to

only those that are really interested

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in advancing extracorporeal life

support, but expansively inclusive

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with all of those with that interest."

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And I love how multidisciplinary our

world is, not just in the clinical

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setting, but in the lab setting, the

basic scientists, the engineers, everybody

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that's part of advancing science.

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We've needed everybody to be part of

the success of ECMO so far, and we'll

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continue to need everybody to make

advancements like this in the future.

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Dan: It's so interesting hearing

that 'cause there's so many-- there

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are multiple different models for

how you would build an innovative

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sort of cutting edge new idea

about how something works, right?

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A-and there's no guarantee that

the model that Elsa followed would

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have had to have been like that.

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So you could imagine an alternate universe

where it looks a lot more like what Bell

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Labs did or what a Skunk Works looks

like, where there's one place that is

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the epicenter, and everybody comes to

that place and works in that place, and

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you design a thing that works in that

place, and then afterwards you figure out

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how to implement it in other locations.

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And instead to take the opposite

tack to be like, "Look, there

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are people all over the world in

little pockets working on this."

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So from a very first standpoint, we

understand this is a thing that has

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to work multiple systems, multiple

medical universes, multiple sets

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of tools, multiple different drugs,

multiple different training pipelines,

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and we have to create a thing that

builds into all of those spaces.

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So let's bring the folks together,

and this, uh, that-- this quote is

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just amazing, "You need everyone,

and they all need each other," right?

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That's what it takes to actually

push it from a theory into reality

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at all of these different locations.

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That, that's just, that's such an awesome

thing to think through that concept.

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I'm glad you shared the,

the mission statement.

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I was hoping that we would come into that

sense of exclusivity and inclusivity as a

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mirror, that it's only for this, but that

also it is for everybody that does this.

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It's inherently multidimensional

and multidisciplinary.

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Um, so when you took the

reins, congratulations, here's

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this giant world crisis.

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Right.

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So y-you have as substrate and back

skeleton underneath you this sense of,

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all right, we have people in other areas.

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We already agree that we work together.

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We already know that the data we share

is bigger than the sum of the parts.

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There's synergy, and there's

shared mission in all of that.

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How did you take that and decide to move

that forward in the way that you all did?

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Christine: The beautiful thing

about that is thank God it wasn't

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just me deciding these vents.

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And we have an amazing group of people

that are part of this community, and

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people are willing to help each other.

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And boy did that come front and center

on full display around the world.

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People would meet.

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We had one group of meetings that we'd

meet every day at seven AM and again

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at seven PM to catch everyone in every

country around the world, just like what

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the latest things that were happening,

what do we know, what do we learn?

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We started a bunch of WhatsApp

communities, not a bunch, but one or two,

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where anybody could contribute what they

were learning and try to help each other.

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And so we were doing a couple of things.

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One, in real time communication,

patient by patient almost.

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This is what's happening

with this patient.

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What's your advice?

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And people would give advice.

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And as things happened, we would learn.

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So real time conversation support at

the patient by patient level, and at

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the same time flipping the registry.

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This broke all the rules we had, but

we thought it was imperative because

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we were also hearing countries were

making decisions about whether to offer

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ECMO to COVID patients based on what

had already been published or learned

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about the experience in Wuhan, China.

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And they were doing probably what

anybody would do, just wait a little

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while, see if normal things work

like everyone recommends, and when

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those don't work, you, you try ECMO.

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But they, for COVID, they tried a

little late in their early patients,

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and that was one of the learnings,

is that you shouldn't wait so long.

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And the other learning was

keep 'em on a little longer.

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And this was something we could

see through our data, but more

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importantly, all of the other

considerations that we had.

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And so as we changed our registry so

that we had a COVID addendum, which

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really we built in like a month,

and that was not me, that was we.

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All of these things were we.

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But just to put that out

there, people contributed.

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And because of that, we had more data

than anybody else that demonstrated

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improvements with ECMO, that it was

something that could help COVID patients.

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And as people did that and shared

what they were learning in real time,

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more patients got access to ECMO

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Dan: So there's certainly a, a scale

effect here or there's some word for

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it I'm blanking on that describes this

phenomenon that the more connections

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and the more power a network has,

the more useful it is, right?

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So as more cases get added and

more people start thinking about

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it, it takes on a life of its

own and, and cascades like that.

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I'll try to remember

the name for this later.

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But can you talk me more through the

initial decision to open the registry?

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'Cause there's a lot of organizations

that would have decided not to do

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that for one reason or another.

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Preston: Yeah.

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Dan: What was it-- What was that like?

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How did that reflect on the

background you al-already had built,

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or how was that decision made?

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Christine: Like many things in a

society like this, what's best for

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the patient or the upcoming patients,

things that we knew we didn't have

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the luxury of in this moment was time.

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We also didn't have the luxury of time

for publishing our findings, nor did

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we have the luxury of time for public-

publishing things like guidance documents.

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And we agreed together that the

trade-off of getting information out

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there to people was more important

than getting things perfect.

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Hmm.

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And it was easy in some ways, like

to just start building the COVID-19

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addendum to the registry, making it

live, that we did with our IT folks

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who really worked by our side, like

so many people around the clock.

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Like there wasn't-

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Dan: Absolutely

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… Christine: Monday through

Friday of anything.

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No one knew what day it

was most of the time.

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You just…

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Or what time it was.

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But if you wake up at 4:00 AM, you're

late, and that's how I felt every

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day, because by the time I woke up

by then, all the stuff that was going

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on in Australia and the Asia-Pacific

region was in the throes of the day.

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So you're late at 4:00 AM, and

that's how it felt every single day.

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But everybody pulled together, and

everyone contributed their data.

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We had people that had all of

their gear on and can't hurt, so

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how do we make something to…

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Do you have ECMO capacity?

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Yes or no?

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What can you hit in your, when you've

got your PPE on that's easy for you to

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tell us do you have capacity or not?

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Let's keep it simple.

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We don't care why.

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Just tell us yes or no.

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So that was another thing that we did.

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Besides the registry, we also knew we

have a global map of all the centers that

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provide ECMO, that are centers of ours.

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No more provide ECMO than this,

but things we could show the world.

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And by the world, in normal times

like today, the people that look at

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our website is not the Wall Street

Journal or a local TV station or

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a patient or their family member.

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But during the pandemic, all of those

types- That's right … of people did.

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And so we needed a quick and easy

way to say, "Here's where there's

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capacity for ECMO right now."

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Not why, not when's it gonna be

resolved, just green light means

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yes- Sure … we have capacity.

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Yellow, maybe.

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Red, no we don't.

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And so we set up an ECMO capacity,

that availability map also as part

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of this way to improve access to ECMO

for anyone no matter where you are.

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You look near you, and our best tool

for quality of data was to timestamp it.

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Teams were busy.

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Hmm.

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So if that hadn't been updated in a

week, the data's not that reliable.

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And so that's how we made ECMO

capacity map available to people.

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Dan: It-- There's- As I reflect on

working through the middle of that, the

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command and control structure of how a

lot of this stuff worked changed very

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dynamically and very rapidly, right?

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So in a lot of cases it was, "Look,

we don't know," and so the frontline

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providers or in small groups were making

decisions about what they would offer

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and how they would offer it based on

their best available ideas, right?

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So where in normal times, as you're

describing, there might be a very

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thoughtful approach and, like,

measured guidance and pro/cons and

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weighing the evidence, here we were

saying, "Look, this is our best guess.

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Here's what we have to offer," and

then each group on the ground is

356

:

gonna figure out what they can offer

within that structure and that space.

357

:

Preston: Yeah.

358

:

Dan: And not all professional

organizations-- I'm not sure how

359

:

to put this in a friendly way.

360

:

Like, not all professional organizations

did things that were so useful or that

361

:

were empowering to the other communities.

362

:

And th-this wasn't the reason that any

of us were doing this work, but if you

363

:

look back at it, it's a very interesting

cross-section of, like, how do you

364

:

think about your space in the universe?

365

:

How are you willing to

adapt to changing times?

366

:

And how do you make decisions when

the universe changes around you?

367

:

'Cause for every one of you all,

there were other groups that were

368

:

saying, "Don't do anything that's

not proven," or, "We're gonna, we're

369

:

gonna wait and see," and other stuff.

370

:

And that's not-- It's

just a different tack.

371

:

But once you start from that structural,

the underlying belief in your vision

372

:

of what you do, then it makes sense and

follows that, of course, we would take

373

:

this decision and this is how it will

look, like the way that you described.

374

:

Our job is to protect the patients.

375

:

This is what it looks like.

376

:

This is our best evidence.

377

:

We believe already that all of these

different centers have their own capacity

378

:

and their own ability to do good, so

let's give them the most up-to-date

379

:

information and see what they can share.

380

:

When you actually made that

decision, was that democratic?

381

:

Was it hierarchical?

382

:

Was that-- I know it's a we and not

a you, but at the end of the day,

383

:

were you, like, pushing a go button

for this or was this, like, a vote?

384

:

How did this look?

385

:

Christine: At the end of the

day, I am pushing a go button

386

:

for the things that we do.

387

:

Dan: Sure.

388

:

Yeah.

389

:

Christine: But I do like to do

that in a way that I feel like I

390

:

have general consensus or support.

391

:

There-- And I don't mean to Portray

that there wasn't a healthy debate

392

:

Dan: Yeah, perfect.

393

:

Christine: There's a healthy debate.

394

:

Pe-- It's uncomfortable- Right … to do

things that are fast and very different.

395

:

It's uncomfortable to not have the

evidence all laid out the way you'd like.

396

:

But it's also not only

uncomfortable, but sometimes

397

:

unethical to withhold information,

e-especially in a time of crisis.

398

:

And in our world, and anybody that's in

the ECMO world will know how even our own

399

:

studies are sometimes deemed unethical

if one of the arm means, arms of a study

400

:

means de-denying people access to ECMO.

401

:

And so- Sure … this whole how do you

do ECMO research anyway is more from a

402

:

play the winner strategy that Bartlett

came up with early on and Pearl O'Rourke

403

:

intelligently modified quite a bit, but

that it's challenging to do research where

404

:

mortality is a real alternative- Yeah

405

:

that you have to face.

406

:

So I think our community is, in some

ways, used to those trade-offs in a

407

:

way that maybe others are less used to.

408

:

Dan: No, that's really well said.

409

:

And I, I think often about the airway

registry studies on the emergency

410

:

medicine side that talk about the

failure of surgical access like

411

:

crics and front of neck access.

412

:

Yeah.

413

:

And, and if you dig into those

studies, a lot of them talk about

414

:

how the biggest failure is the

failure to do it early enough.

415

:

Mm-hmm.

416

:

Like, basically, once you commit to that

path, then y-you're generally fairly

417

:

good at it, but people are very hesitant,

understandably, to commit to that path.

418

:

And-

419

:

Christine: Never

420

:

… Dan: if you follow that logic

backward, you realize that you're

421

:

almost never gonna feel like it's the

right time to take this next step.

422

:

'Cause if you wait till you feel

like it's the right time, you've

423

:

probably waited too long to actually

pull the trigger on the thing.

424

:

And getting used to that, that paradox

almost, that you're supposed to be

425

:

building up information, you're supposed

to be building up belief, you're

426

:

supposed to be building up evidence,

but at some point, the reality is you

427

:

have to switch gears and take that

next step before it feels comfortable.

428

:

And it strikes me that's i-in some

sense at a different level what you're

429

:

describing, which is that you have to make

the decision to move your organization

430

:

away from the traditional path.

431

:

It will never feel comfortable

to make that decision.

432

:

There's no amount of evidence that will

ever, at that time that you have it, make

433

:

it okay or not okay, and you have to be

used to taking that sort of a leap for it

434

:

Christine: Hmm.

435

:

That's well described.

436

:

Dan: Yeah, I'm so fascinated

by this because, again, the--

437

:

like, we're talking a level of

abstraction higher than we normally

438

:

think about on the podcast, right?

439

:

We're talking about a system behaving

in a way that we're used to talking

440

:

about individuals and teams behaving.

441

:

And anytime we see that, that mirror, I

try to highlight that and be like, "Why

442

:

did we do that, and what were the factors

that allowed that thing to happen?"

443

:

And I could make some guesses.

444

:

Uh, you've highlighted some of them that

maybe we're more used to making that

445

:

type of decision than other groups are.

446

:

I would throw into the pot, we al-

you already believe that there are

447

:

multiple correct ways to do a thing.

448

:

There's all these different groups around

you who have their own version of ECMO

449

:

that you're trying to gather to source,

and you probably already believe that

450

:

you're at the, for lack of a better way to

put it, the cutting edge of truth, right?

451

:

Nobody knows how to do it better

than what you all are doing.

452

:

You're discovering that coal face

even as you're hammering away at it.

453

:

And those threads seem like they

would put that, put your group at

454

:

a really interesting location to

make that decision, whereas other

455

:

groups without those threads might

have had a harder time with it.

456

:

I realize this is like a leading question.

457

:

I don't know.

458

:

What, what else would you throw into

that soup if you're thinking about that?

459

:

Christine: Well, one thing that

you just said that our group--

460

:

Here's where I would have to offer

potentially something about how Dr.

461

:

Bartlett thought about things, and that

is anybody can contribute a great idea.

462

:

It really can come from anywhere.

463

:

It doesn't have to be in our group,

which makes everyone part of our group.

464

:

And so we're never done

looking under the next rock.

465

:

We're never done listening to a person

that has an idea that's observed something

466

:

that maybe somebody missed or just thought

of this because they were listening to

467

:

great music, some song, and it inspired

them to think of something else.

468

:

Who knows?

469

:

But you have to be open to

ideas coming from everywhere.

470

:

And so we're-- I like

the way he worded things.

471

:

We're exclusive.

472

:

You're-- We're only for people

that care about ECMO or ECLS.

473

:

But everyone, we need everybody that's

interested in that space, and that's

474

:

still true, very much true today.

475

:

The place I would look to next is

systems upon systems, and that is Some

476

:

of the work today, actually during the

pandemic too, that is being done on

477

:

out-of-hospital cardiac arrest, that

really requires systems upon systems to

478

:

do that well, where you've got people

in the field identifying and knowing

479

:

what to do for somebody when they go

down, not knowing really much about it

480

:

except they're functional one second

and the next second they're not so much.

481

:

And then what?

482

:

And that's where the systems upon systems

kick in to improve access to ECMO for

483

:

those patients too, which are not…

484

:

It's very different than a patient

going into cardiac arrest on the seventh

485

:

floor that's in the cardiac ICU, and

you know where the cath lab is, or heck,

486

:

you could just bring the ECMO team to

them, and you call them, and they're

487

:

there in five minutes, maybe seven,

versus how long have they had good CPR?

488

:

What do you know about them?

489

:

What are their presented comorbidities

'cause you can't talk to them?

490

:

And how do you get all the different

pieces and parts of the system to work

491

:

together so that patient has access

to ECMO, so you just buy that patient

492

:

some time to then sort out what's

really going on and solve that problem.

493

:

And that piece has been done increasingly

better and better by many people, but

494

:

I'd have to point to Dimitri Yanopoulos's

team at the University of Minnesota

495

:

to say who's really set a high bar

and demonstrated things well with

496

:

the ARREST trial that was published

actually in twenty twenty as well.

497

:

So at the same time we're doing all

these things with COVID patients,

498

:

and you can see that even the data

in our own registry, the cardiac

499

:

patients Went down quite a bit.

500

:

So those patients just

didn't make it that far.

501

:

It's not that we had less heart

attacks, it's not less like

502

:

we had less cardiac issues.

503

:

We just changed our system's capacity

and focus on respiratory disease, and

504

:

our resources got consumed with that.

505

:

Sure.

506

:

So there were a bunch of things going

on, and it's hard to do a randomized

507

:

controlled trial on that and see,

but I think there's been some good

508

:

studies on the public health side of

things that have demonstrated that

509

:

we just missed some people on the

cardiac side during those times, right?

510

:

Dan: Absolutely.

511

:

Who didn't present?

512

:

Who stayed home?

513

:

Yeah.

514

:

Who wasn't-- Who didn't get the…

515

:

There's a big question underneath this

that, and this is one of the things

516

:

that, that we explored during our session

at the LSO conference, but what does

517

:

excellence really look like in this space?

518

:

And it's so easy to define

excellence in some fields.

519

:

Not that it's easy to ach-achieve

it, but it's easy in some

520

:

sense- Right … to define it.

521

:

Preston: Yeah.

522

:

Dan: You know, if you were excellent

in the hundred meter dash, you run

523

:

hundred meters faster than, you

know, this timeframe or whatever.

524

:

The baseline mortality rate is so

high, the number of controllables

525

:

is so wide, the teams and systems

and everything interacts together.

526

:

Defining what excellence really

looks like i-is actually like a very

527

:

hard skill set and a moving target.

528

:

And what excellence looks like in a small

hospital that has one or two folks that

529

:

can do ECMO is gonna look different than

what it looks like in a large academic

530

:

center w-that has twenty-four/seven

ECMO coverage and everything else.

531

:

When you're-- When we're talking

about this in terms of who got the

532

:

best that they could, who was offered

our best chance, the numerator and

533

:

the denominator are both changing at

all times about that, and it makes

534

:

it a really challenging target.

535

:

But-

536

:

Christine: Yeah

537

:

… Dan: when we think about this from

the ACLS side or the stroke side,

538

:

for example, we often talk about

like the chain of survival, right?

539

:

Which is some version of we identify the

problem, we devote like local resources

540

:

and responses to it, we have extra

resources that swarm in, we transport

541

:

the person to a center of excellence,

and then we do stuff with them.

542

:

Mm-hmm.

543

:

Loosely defined.

544

:

There's better ways to describe

that, but that's, you know, the idea.

545

:

Stuff happens.

546

:

Stuff happens.

547

:

Yeah.

548

:

Stuff happens.

549

:

Things get done and-- But when you're

talking about the systems of systems,

550

:

is that still the right model?

551

:

Or because ECMO is by definition

multidisciplinary, multi-professional,

552

:

resource intensive, is there

another model that's better to think

553

:

through when you're thinking about

the systems of systems approach?

554

:

Christine: You-- It sounds

like you might have an answer

555

:

to that question already, Dan.

556

:

I don't know the answer, but here's

what I would say we're thinking

557

:

about, and what I think about is

how do we enable more of this?

558

:

So that is, how do you enable more

outside of your hospital or your ICU

559

:

or your cath lab or OR, ER setting

so that more different groups.

560

:

If you think about the EMS providers,

let's talk about LA County just because

561

:

they've done a lot of work on this.

562

:

Actually, I've met with the CM, s-

chief medical officer of LA County, and

563

:

they've been doing some work thinking

about who they should be sending

564

:

their ECPR, potential ECPR patients

to, and they wanna pick hospitals

565

:

that they know will do a good job.

566

:

But LA County isn't just LA County's EMS

providers, it's all the private providers.

567

:

It's all the other services.

568

:

It's the ones that fly people

in and out that are there for

569

:

mult- like super regional areas.

570

:

So all of them, if we can get all of

them to think similarly about candidates,

571

:

to know where to send them, to have

similar kinds of guidance that's top

572

:

of mind to where minutes matter to get

patients to What isn't just any place,

573

:

but the best place for that kind of care.

574

:

Dan: Yeah.

575

:

Christine: Yeah- Like, that's part of what

we're talking about is, like, you've got

576

:

so many different players in this layer.

577

:

So let's just talk about

your emergency responders.

578

:

It's the fire departments, it's

your EMS teams, and it's all

579

:

the different providers of EMS

that are part of that system.

580

:

Then your referring hospitals are another

layer where they have some resources.

581

:

They might be the best

first place to get somebody.

582

:

Can they cannulate and ship there?

583

:

Maybe they can, and maybe if

we teach- Yeah … more of them

584

:

to do, that could work better.

585

:

We'll see.

586

:

But it's that kind of systems

thinking about all these pieces

587

:

that make up that opportunity to

get somebody on, secure on ECMO.

588

:

So then you've got…

589

:

You're buying yourself a little

time on behalf of that patient

590

:

to solve the real problem without

putting more organs at risk.

591

:

Dan: Yeah.

592

:

And I've been working in LA County.

593

:

I've been on the receiving end of many

of those patients in the emergency

594

:

department with one reason or another.

595

:

We also, we wrote a paper a few years

ago with a sort of funny title of Rubber

596

:

Meeting the Road that actually- I saw it

597

:

looked at access to comprehensive

stroke centers at different times

598

:

of the day within LA traffic.

599

:

So if you look at, like, the actual

intersection of real lived reality

600

:

versus, like, the theory of who's

supposed to be able to get to where when

601

:

and really digging into it, but which

was a wonderful project to work on.

602

:

But I know I asked that as a leading

question, and I'm, I'm sorry about

603

:

that . I actually think, like, both

of those answers are true, right?

604

:

There are parts of this very complex

system that at least from, you

605

:

know, m- my perspective, are very

different than in large quotes, just

606

:

the simple chain of survival model.

607

:

But then there are parts that actually

look exactly like that, and understanding

608

:

what angle you're viewing it from or

what are the pinch points where, when

609

:

something has to go a certain way in

order for us to bring online a much

610

:

more sophisticated, interesting, and

also costly set of skills and abilities.

611

:

The-- I actually don't know

what the answer to that is.

612

:

And, and I would imagine that there's

some ways in which it's true and some

613

:

ways in which it's different and,

uh, an area of active exploration.

614

:

I think you, you hit the nail on

the head when you said it's a, sort

615

:

of like a complex system of complex

systems at every layer of which has

616

:

a variety of players with different

skill sets and patterns in there.

617

:

I wish I had a clean cut

answer to that, but I don't.

618

:

Christine: Yeah.

619

:

I don't either, but I'll tell you a

fun tool I saw at EuroELSO's conference

620

:

last year in Milan, which was a drone

that you, of course, could sit in

621

:

as the physician, the ECMO provider,

with an ECMO pack on your back, and

622

:

you could just fly yourself to the

scene and cannulate the patient there.

623

:

So I asked this provider, I'm

like, "Have you done this at all?

624

:

Has anybody used this?"

625

:

"No, not yet."

626

:

"Well, you need a pilot's license,

and you need to work with the FA."

627

:

Okay, I get it, but- That's

awesome … it was a cool display.

628

:

It was such a cool display,

Dan, I have to tell you.

629

:

Like, I can't tell you how many of

my, like, friends and colleagues

630

:

were like, "I'm flying this thing."

631

:

Like, it could be in-

632

:

Dan: Totally

633

:

… Christine: that feather

layer entirely, so- Yeah

634

:

… Dan: who

635

:

Christine: knows?

636

:

But if you could just get yourself

into this little dress thing, you

637

:

go to the pa- where's the patient?

638

:

Okay, they're on the side of highway

whatever, I'll be there in 10 minutes.

639

:

Dan: Yeah, jetpack deployable ECMO is,

it sounds really like the forward future.

640

:

That's awesome.

641

:

Yeah.

642

:

Christine: So who knows?

643

:

But I think those kinds of tools

too probably have a role someday.

644

:

Dan: Sure.

645

:

Christine: They probably

have a role someday.

646

:

Dan: Yeah.

647

:

And I guess this is a great way

to pivot into this, but we've

648

:

talked a lot about the origin of

also some of these big moments, a

649

:

little bit about systems of systems.

650

:

But as we're, like, angling towards

the end of this episode here, what

651

:

do you see as the future of this,

and how does an organization like

652

:

this continue to help folks really

push the edge of what's possible?

653

:

Christine: No, that's a great question,

Dan, with so many possible answers.

654

:

But I know things that we're

thinking about, especially with Dr.

655

:

Bartlett passing pretty recently.

656

:

Ho- honestly, it's October 20th,

it's still hard to process sometimes.

657

:

I'm used to having him-

658

:

Dan: Yeah

659

:

… Christine: around.

660

:

But, uh, doing things the way

he would do things is really

661

:

important to me personally.

662

:

And so there's so many areas

of work we have left to do that

663

:

it's, it's almost limitless.

664

:

There's the systems of systems

things we're talking about.

665

:

There's still a lot that

could be improved with ECMO.

666

:

There's the role of organ donation,

and there's already a role ECMO plays

667

:

there, but his lab and other labs

have long been investigating organ

668

:

perfusion, so you could maybe get to

organ farms someday, if you can imagine.

669

:

But-- and talk about having an impact on

saving more lives, that would change the

670

:

game entirely on how when an organ becomes

available, you look at the qualified

671

:

people and the tactics of getting that

organ to somebody and who's on that list.

672

:

And if you had not six hours but

seventy-two hours or a week, it would

673

:

really change the game for patients

that are waiting for an organ- Mm-hmm

674

:

and save a lot more lives.

675

:

So there's a role in so many

places, but even in materials Fluid

676

:

dynamics, oxygen exchange, carbon

dioxide, getting rid of carbon

677

:

dioxide in the system or other ways.

678

:

Like, there's some basic things

there, making the system easier

679

:

to operate, less likely to fail.

680

:

There's all kinds of work on

the engineering side of things,

681

:

and that's everybody, basic

science and everybody from basic

682

:

science to clinical application.

683

:

The systems work in getting hospitals

to set up good ECMO programs, like

684

:

high-functioning ECMO programs where

teams are supported and they're

685

:

not having to really advocate

hard for the resources they need.

686

:

That would be a huge lift.

687

:

Mm.

688

:

And we're looking that one straight in

the eye with our center certification

689

:

program that we'll be launching next year.

690

:

That's about 50 people from around the

world that have worked for two years

691

:

to try to define what we think might-

692

:

Dan: Wow

693

:

… Christine: a program need by level.

694

:

And if we can do that well, we will

have a global map that has the level

695

:

that is the scope of services that are

offered center by center, so that it's

696

:

no longer confusing or people can't…

697

:

They may still do this, but they,

if they're certified, they'll be

698

:

certified for the scope of services

that we can certify them for, and

699

:

that might help really improve

access to care that's clear.

700

:

That was one thing we could not do during

the pandemic that I still regret, which

701

:

is having a super regional approach to

care, and I'm hoping we can get there

702

:

because if something big like this

happens again, we need to be more ready.

703

:

Dan: Yeah.

704

:

Absolutely.

705

:

Christine, thank you so much

for joining the podcast.

706

:

This has been amazing and

enlightening and, like, also

707

:

just really fun to talk about.

708

:

A-as we're closing out, I wanna

give you a chance to challenge

709

:

everybody listening to this, right?

710

:

So anything you want them to do

differently after they walk away from

711

:

listening or watching this episode.

712

:

And to give you a little time to stall,

I'm gonna put my normal disclaimer

713

:

in here while we're doing this, which

is that our job here on the Emergency

714

:

Mind podcast is to take the best of

what everybody has already figured out

715

:

about applying knowledge under pressure

and share it broadly with the world.

716

:

Nothing we do here is medical advice,

and for myself or any of my guests, our

717

:

views or anything we say are just our

own and don't represent any of the many

718

:

wonderful groups we work for or with.

719

:

Hopefully, that's it, uh, and that

gave you enough time to come up with

720

:

a fun challenge, but what do you

wanna-- what do you want people to do

721

:

differently after they, they leave this?

722

:

Christine: It's not…

723

:

It, it's two things.

724

:

Not so much differently, but one is just

a real commitment to science and the data

725

:

that we share, that Bob initially started

the society with, that people were really

726

:

enthusiastic about, and let me tell you,

they hand wrote all their data from the

727

:

patient medical records that they had.

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:

"Here's everything we know

about Susie Smith and Mr.

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:

Jones," or whatever it is, and mailed

them to Bob in, in Ann Arbor, and

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that's how we created the ALSO Registry.

731

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It's now much easier to

use, but it's important that

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people contribute their data.

733

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We still have so much to learn, and so

it's just this commitment to science

734

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in medicine that I feel sometimes gets

eroded depending on our surroundings.

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It's not easy to do and stay committed

to, but it's paramount for our success.

736

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And the last thing is to be involved

and be part of our community.

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:

If you're at all interested

in this space, we need you.

738

:

Dan: So cool.

739

:

Christine, thank you so much

for joining the podcast.

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:

Christine: Thanks for

the opportunity, Dan.

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:

This was very fun, and,

uh, I appreciate it.

742

:

Thanks.

743

:

Preston: Thank you again for

listening to our Teamcast.

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:

If you found value in this discussion,

the best way to support our work

745

:

and ensure you don't miss future

episodes is to subscribe and

746

:

leave us a quick rating or review.

747

:

It'll help us reach more people who

need to hear these conversations.

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For more on Mission Critical Team

Institute, including all of our episodes

749

:

and show notes, visit missioncti.com.

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:

You can also connect with us on LinkedIn.

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:

And if you're a mission-critical

team looking to learn more about

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:

our programs, reach out directly

to our Director of Operations, Ms.

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:

Janese Jackson, at janese@missioncti.com.

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:

That's J-A-N-E-S-E@missioncti.com.

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:

Until next time, thanks.

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About the Podcast

Teamcast
Mission Critical Team Institute Teamcast
Dr. Preston Cline, Dr. Dan Dworkis, Dr. Art Finch and Harry Moffit of the Mission Critical Team Institute share research and explore the questions vexing the most elite teams in the world, from Special Operations soldiers to Firefighters, from Trauma Medics to Professional Athletes, and from Astronauts to Tactical Law Enforcement.

About your hosts

Coleman Ruiz

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Co-Founder and Director of Performance, Mission Critical Team Institute

Preston Cline

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Co-founder and Director of Research and Education at the Mission Critical Team Institute
Senior Fellow, Center for Leadership and Change Management, The Wharton School, University of Pennsylvania