oa ECMO transport challenges in India

Transport of extracorporeal membrane oxygenation (ECMO) patients in India, where there are very few ECMO centres, is a real challenge due to the huge area and large population of the country, and the diversities of resources between urban and rural areas. Road and air transportation are well established but another common mode of transport not fully developed is the train. Road transportation is used in almost 98% of our ECMO transfers. It is cheaper but its limitations are traffic congestions, road conditions, and travel times. The maximum distance covered is up to 250 miles,¹ which represents almost 5–6 h of travel time. Air transportation is a good option for long distances but is costly.² The average cost of air transportation (fixed wing) in India is around US $1600–2500 per hour, and the average run time is 4–6 h. Helicopter is not a preferred aeromedical transportation modality in India. Train transport services could be ideal in India as many superfast trains are covering the length and breadth of the country but the coaches are currently not suitable.

As an alternative option we developed the concept of a mobile ECMO unit, keeping in mind safety and cost effectiveness. It involves taking the ECMO team to the referring hospitals rather than transferring the patient. It is a viable practice as cardiac surgical skills are available in tertiary hospitals. Patients can be cannulated locally and managed by an expert visiting ECMO team in association with the referring team. Advantages:

•  Safer – no patient transfer •  Cheaper – no aeromedical patient retrieval •  Creates more awareness and utilization of ECMO services in different parts of India •  Opportunity to train and develop regional centres.

Drawbacks:

•  Staff need to get adjusted to different environments, cultures, and languages •  Coordinating teamwork with an entire new team

Retrospective case series of patients managed by our mobile ECMO team from August 2010 to August 2016 shows that we have had 45 patients transported during or before ECMO, without loss of life or major clinical or technical issues during the transport phase. Of the 45 patients, 39 had intrahospital transport for investigation like CT scan and for therapeutic procedures in the operating theatre. Of the 39 patients, 35 (90%) were transported on ECMO, while 4 were transported with conventional ventilation before initiating ECMO. Six patients had interhospital road transport while on VV ECMO with an average distance of 130 km (Ranging of 9–250 km). Of the 6 interhospital transport patients, 4 survived (67%) and were discharged alive from the hospital, and the other two patients died after 5 and 7 days on ECMO. The team has provided mobile ECMO services to 121 patients in different tertiary care hospitals and covered so far eight states of India, roughly 20 cities, and more than 50 tertiary care hospitals. The average survival remained around 45%. The average ECMO expense per patient was US $7340 (Range: US $4500–$23,000).

A dedicated mobile team allows safe road transportation of patients with severe ARDS;³ however, in India, where healthcare is self-sponsored, mobilizing the ECMO team and equipment to put a patient on ECMO in the referring hospital is more cost effective and safer. Our ultimate objective is to develop affordable transport services to reduce healthcare costs. Inclusion of ECMO as part of the curriculum for critical care consultants and cardiac surgeons is essential for improving awareness and getting hands on experience in initiating and streamlining the process of ECMO teaching and training. A definitive roadmap for developing Indian critical care services is crucial.