ECMO ON THE STREETS OF PARIS
compared with percutaneous cannulation.
The objective of ECPR is to perfuse the
brain while the cause of the cardiac arrest
is sought and treated at a specialty hospital (e.g., by coronary angiography, CT scan,
etc.). Indeed, the primary objective is to obtain
return of spontaneous circulation (ROSC),
however, long-term survival depends on the
neurological prognosis of the patient.
Once ECPR has been initiated, acceptable
SAMU DE PARIS
blood flow is restored to the whole body, and
especially to the brain and coronary arteries in
order to limit ischemic consequences. Many
studies, both clinical and experimental, have
shown that the blood flow delivered by ECPR
is much higher than that delivered by mechan-
ical compressions/cardiac massage. ECPR is
therefore considered as a “bridge” in order
to have time to treat the cause of the cardiac
arrest. The international results of the utili-
zation of the ECPR are very encouraging. 2–4
SAMU is a free public service in charge of
responding to EMS calls in Paris. SAMU
operates Department 75, a single medical dispatch center for the whole city of Paris. In
the rest of the country, there’s one SAMU
All calls to SAMU are screened by a doctor.
The administrative information and reason
of the call are initially taken by an assistant
dispatcher who transfers the call to a dispatch doctor.
The doctor’s role is to give the most appro-
priate medical response depending on the rea-
son of the call and the degree of severity and
emergency: referring the patient to a general
practitioner, sending a general practitioner to
the patient’s home, directing the patient to the
nearest ED, or dispatching the most appro-
priate means of transportation or care (i.e., an
ambulance, a firefighter BLS unit or a mobile
intensive care unit [MoICU]).
The French prehospital system is based on
the possibility of a MoICU being sent out to
The MoICU is usually composed of three
people: an emergency physician or anesthesiologist intensivist, a nurse and a paramedic.
The ambulance used by the MoICU contains everything a physician would need to
treat an acute patient in hospital ED or ICU.
This system is the opposite of the “scoop and
run” concept, as we send the hospital to the
patient in order to evaluate the patient on
scene, make a diagnosis, stabilize and/or treat,
and transport the patient directly to the most
appropriate service. This could mean transporting straight to the catheterization lab for
an acute myocardial infarction, to the ICU
for a coma which has required intubation, or
to the operation room for an unstable aortic
dissection needing immediate surgery.
This system can do everything from “stay
and treat,” such as prehospital ECPR, or “run
and treat,” in the case of penetrating trauma
for a damage control situation.
In the case of a call for a patient in cardiac arrest—witnessed or diagnosed over the
phone—a BLS team, operated by the Paris
Fire Brigade, is immediately dispatched
along with the SAMU MoICU team. Dispatch guides the witness in bystander CPR
over the phone.
The BLS team is usually first to arrive
on scene, with a mean arrival time within
nine minutes in Paris, followed by the
ALS is then delivered on scene until ROSC
is obtained. Depending on the presumed etiology of the cardiac arrest, the patient can be
taken directly to the catheterization lab for
immediate coronary angiography, to CT or
to the ICU. The dispatching of the ECPR
team and decision-making in the case of a
refractory cardiac arrest will be described later.
When the first disappointing results of
in-hospital ECPR for OHCA were published (4% of survival in patients presenting refractory OHCA being brought to the
The Paris ECPR response team treats patients wherever they may be—from subway stations to streets
to the famous Louvre Museum.
On-scene ECMO protocols require that ECPR be implemented after just 20 minutes of CPR with an AED—the
optimal time to switch from conventional CPR to ECPR according to recent studies.