Before the COVID-19 pandemic hit the United States in early March, not many people knew about the existence and necessity of a procedure called extracorporeal membrane oxygenation, also known as ECMO. This invasive, life-saving technique artificially drains blood out, oxygenates it, and pumps it through the body to fuel red blood cells in patients who suffer from insufficient blood oxygenation levels, similar to heart lung bypass. This is often due to acute failure of the heart and/or lungs. Many COVID-19 patients are also being given ECMO as a last-resort procedure when ventilators do not provide sufficient oxygen throughout their entire body.
Connection to ECMO is a complicated procedure requiring insertion of large bore tubes into major blood vessels which are then connected to the pump. This is usually performed by a cardiothoracic surgeon, trained intensive care specialist, or team of expert surgeons, staff, and nurses, leaving little opportunity for a novice to practice on a real patient. An incision is made in the skin and tubes, or cannulae, are placed into a large vein and/or artery in the chest, neck, or groin. The blood is then pulled from the body, passed through the artificial lung, oxygenated, and cycled back into the body using the ECMO pump. Aside from COVID-19, it is often used when patients are coding and doctors need to mechanically support their heart and lungs to prevent death. Time is of the essence and stakes are often high when performing this procedure, leaving little room for error.
Dr. Jai Raman, formerly of the University of Chicago & Rush University Medical Center in Chicago, Illinois, and currently of the University of Melbourne in Melbourne, Australia, expressed this concern to T. Kesh Kesavadas, director of the Health Care Engineering Systems Center at the University of Illinois at Urbana-Champaign. “Inserting cannulae into patients that are critically ill can be challenging and fraught with complications due to injury of the vessels,” said Dr. Raman. “Simulation platforms for this procedure, where trainees and physicians can practice on a manikin or through virtual reality, would help. This would make access of the vasculature and insertion of the tubes effective, safe, and seamless, ultimately improving patient outcomes and survival.” They applied for a grant to study this problem.
After this conversation, Kesavadas and his team at the HCESC, whose mission is to improve patient outcomes through collaboration between engineers and physicians, began developing a simulation platform to educate students and clinicians in administering this life-saving procedure. Their ECMO Training Simulator was completed in 2018, in partnership with OSF HealthCare through the Jump Applied Research in Community Health through Engineering and Simulation endowment. It is now being used in a research study conducted by the U.S. Air Force En route Care Research Center.
“Simulation training is necessary to improve patient outcomes,” said Kesavadas. “HCESC has been a leader in developing this technology since 2014.” HCESC is a research unit housed under The Grainger College of Engineering. Their primary area of research is in simulation technology, but they also have expertise in surgical robotics, health data analytics, and smart health. HCESC also manages the Jump ARCHES endowment, which was established in 2014 as a partnership between The Grainger College of Engineering and OSF HealthCare, a large health care system serving central Illinois. The endowment promotes collaboration between engineers and physicians from OSF HealthCare and the University of Illinois system. They accept project proposals twice yearly, and one Principal Investigator needs to belong to each institution to be eligible for funding.
Dr. Matthew Bramlet, pediatric cardiologist at OSF HealthCare, and Pramod Chembrammel, research scientist at HCESC, teamed up and applied for Jump ARCHES funding to create the ECMO simulator. “My background is in pediatric cardiology and advanced cardiac imagining, and I collaborated with Pramod in building a database of 3D models of various cardiac pathologies that he uses in simulations,” said Dr. Bramlet. “As health systems tighten budgets, the number of experienced ECMO providers may decrease which will increase the need for high-fidelity simulators to maintain a higher level of expertise among those performing ECMO.”
Bramlet and Chembrammel applied for a Jump ARCHES grant in 2016 and were awarded funding to create the simulator, which consists of a torso manikin and cannulation tubing structure that can be inserted into the femoral or jugular regions of the manikin, connecting to a programmable pump to drive fluid through the tubes.
Creating the ECMO simulator would not have been possible without the team and expertise at HCESC. Simulation engineer Anusha Muralidharan began working on the project in 2018, primarily working on hardware and sensors. “ECMO requires auto-monitoring of blood flow, pressure, and temperature. It’s vital that sensors are able to monitor it correctly,” said Muralidharan. This technology helps replicate difficult scenarios in ECMO by interfacing with mathematical models of human physiology, which is what drew research scientist Dr. Inki Kim to working on this project. “Design and validation of cyber-physical systems is a great challenge. The ability of this simulator to create unlimited cases of pathophysiological scenarios helps optimize learning, realism, and complexity,” said Dr. Kim.
After completing a prototype of the simulator, HCESC presented a poster of their new technology at the Military Health System Research Symposium in 2019. They connected with a surgeon from the U.S. Air Force En route Care Research Center, who was intrigued by the technology and was interested in using it to see if it was effective in training military medicalpersonnel. Kesavadas, Muralidharan, Kim, and the rest of the team at HCESC prepared the technology for institutional use by writing manuals, manufacturing and assembling a new simulator, and packaging materials for delivery. HCESC eagerly awaits reports on usage and outcomes of the technology to further confirm the importance that simulation technology has assumed in training medical professionals.
Simulation technology has grown even more important in a time where most learning is taking place over virtual platforms. Unfortunately, this is a time where learning is most important in the medical field due to the high probability of specialized medical personnel becoming infected with COVID-19, leaving others to perform their tasks. “When ECMO is needed, you want the procedure to happen at the patient’s bedside within minutes and be available 24/7,” said Dr. Mark Johnson, director of the Intensive Care Unit at Carle Foundation Hospital in Urbana, Illinois. “To do this, you need an entire team of four to ten people that are trained in performing the procedure.” Johnson cited two local cases of COVID-19 that required the use of ECMO and anticipates performing the procedure more during a potential second wave of the pandemic.“Simulation training would be extremely important for this procedure at Carle.”
ECMO is gaining acceptance in the medical community to salvage and support patients in critical condition, but uniquely to pandemics and seasonal influenza. Dr. Abdul Siddiqui, pulmonologist at Christie Clinic in Champaign, Illinois, cited an “exponential rise” in the use of ECMO across intensive care units in the United States since the H1N1 pandemic in 2009. “ECMO requires substantial resources and frequently carries a high risk of complications and mortality. It involves complex decision-making skills in a timely manner,” said Siddiqui.
Decision-making skills and the ability to perform under pressure are best learned before a medical professional ever sets foot in an operating room or intensive care unit. “These skills can be achieved through simulation,” said Siddiqui. “They are an essential part in providing the most effective care to patients, as simulations help to understand the intricacies of the ECMO machine and its interaction with the complex physiology of a critically ill patient.” Simulation technologies are rising to fill the gap between the classroom and operating room, to minimize hesitation and increase the confidence of everyone from novices to experienced surgeons in making split-second decisions that could save lives. Simulation can be used to teach specific skills with manikins, virtual reality, or augmented reality scenarios, allowing novices to practice techniques more thoroughly prior to practicing on a simulated or actual patient.
The Health Care Engineering Systems Center plans to expand the capabilities of the ECMO simulator in the future by adding a virtual reality component. This would enable the user to situate themselves at a patient’s bedside and fully immerse themselves into a 360-degree experience. While the current state of the ECMO simulator allows the user to grasp basic components such as insertion of cannulation tubes, a virtual reality component would allow these skills to be trained amid the high-stress environment of an intensive care unit or field hospital. “With the added virtual reality component, this technology would be revolutionary in changing the way medical personnel are trained in performing ECMO,” Kesavadas said. “We’re interested in collaborating with external businesses or institutions to bring this technology to the consumer market as soon as possible, in keeping with HCESC’s core values of collaboration, partnership, and translation.” A provisional patent has already been filed.
The Health Care Engineering Systems Center was established in 2014 and has grown as a research center where engineering meets medicine in innovative ways, playing leadership roles in simulation, health data analytics, and medical robotics activities on campus at the University of Illinois. They manage the Jump Simulation Center, a 6,000 square-foot, state-of-the-art simulation and education center housed on the University of Illinois campus, established by a $10 million gift from Jump Trading. It is equipped with manikin-based simulators and virtual reality tools to meet the needs of the Carle Illinois College of Medicine, the first medical school in the nation focused- from the beginning- on the intersection of engineering and medicine. The Jump Simulation Center is the culmination of several years of planning; in 2014, a $62.5 million gift established the Jump ARCHES endowment, a partnership between the existing Jump Simulation and Education Center at OSF HealthCare in Peoria and HCESC at the University of Illinois. Through this partnership, the University of Illinois at Urbana-Champaign is striving to expand simulation technology so that it is accessible, beneficial, and revolutionary in training everyone from novice medical professionals to the most experienced clinicians.
The Health Care Engineering Systems Center welcomes all potential collaborations and partnerships. To learn more about HCESC, their simulation technology, and collaboration, please visit https://healtheng.illinois.edu/.