 Hello, my name is David Mast. I'm the Chief of Perfusion Services at the Ohio State University Wexner Medical Center. And I want to welcome attendees to my lecture, Becoming a Smart ECMO Program, a Single Center Experience. If you had spoken to the perfusionists at Ohio State prior to 2009, we would use the four letter word we're referring to ECMO. In our opinion, ECMO did not work for adults. And the primary reason for that was that we had little experience using ECMO and we didn't have the equipment that we needed. And as a result, we had poor outcomes. And so really we had no interest in doing it at all. And in fact, if you had mentioned ECMO, this is probably a response you would have gotten from the perfusion crew back in the day. So what was that four letter word that we would use when referring to ECMO or when ECMO came up? It was no, we wanted nothing to do with it. However, as everyone knows, in 2009, things changed. H1N1 led to a paradigm shift, not just at our center, but across the country. What we saw was patients were being successfully supported that were at H1N1 with ECMO. And so people across the country, our center included, were scrambling to buy up ECMO equipment. And this is what we bought up at the time. And it worked. We were able to support patients with H1N1 and they actually did very well. And so for us, things changed. We saw ECMO differently. In this instance, this is a patient who came to us from an outside hospital. He was a young man on scholarship for rowing to a major institution in America. And what happened was, is he had a small little scratch that led to an infection and it kind of escalated and cascaded from there. They ended up having to bring in a cardiopulmonary bypass machine to support him in a non-cardiac OR because he was so sick and they were losing him. From there, they transitioned him to an ECMO system that they piecemeal together and then they supported him for a day or so while they were reaching out to find someone to take him. And so they did reach out to us knowing that we had recently started an ECMO program and we happily took him at our center. When he came in, he was this very athletic big young man and he had, like I said, he had this whole rowing scholarship ahead of him that he was planning on going to but because he was so big and so muscular, the canyons that they had to use to support him were very large. And as a result, he suffered from distalemischemia and he lost one of his legs as a result. He ended up losing a second leg due to a necrotizing fasciata and so he lost his second leg as well. And so you can imagine the impact that that would have on a young man with a rowing scholarship. It'd be very easy to look at this as a negative. However, this young man completely turned it around. He went back to rowing. He worked really hard. He made the US Paralympic rowing team. He ended up getting named the US rowing male athlete of the year and he went to the Rio Paralympics in 2016. And as a result, ended up going to the White House and meeting the president. So it's very easy in the day-to-day things to get caught up in this and look at it and say, you know, this was a negative, but then you look at what this young man has done with his life since then and it's actually pretty amazing story. So profusion posed 2009. The four letter word, it actually started changing to hope we actually had a belief that we could use ECMO to support patients and get them through whatever illness they might be dealing with. Yeah, there were some bumps along the road that we were on, but we were seeing some success stories and it did give us that hope. So for the early days of ECLS at OSU, we wanted to focus on building the program. That involved the criteria, education, quality, staffing and then expanding the team and expanding our footprint. So as far as building the program, we started with creating the criteria. Early on, it was pretty much a, you know, take all cumbers type mentality and we learned from that. You know, obviously we had some bad outcomes of result and so what we wanted to do is we wanted to create some criteria, which is what we did. Our criteria was pretty basic at the beginning and then we kept evolving it over time. We'd go back and we'd look at what happened on patients that we decided to accept and place on ECMO and how they did. And we just kept making changes. So about every six months to a year, we review it internally and it gets updated every year or two. And then also you need to have an education program for your team. So we started an ECLS class back in the day and we would actually have our bedside providers come in. So all the bedside nurses initially went through this program and they got to go over things like pathophysiology for patients that we would support on ECMO, pharmacology from the pharmacist team that respiratory therapy came in and gave a talk on ventilator management. And then the bedside nursing component of it and then of course the perfusionist would talk about the ECLS circuit itself and the interactions with the patient. And then at the end, we did have an evaluation for them and an evaluation that they would fill out for us. And as a result, we grew from that and we were able to fine tune it and make it better each step of the way. The next step was to create a simulation program. The classes were good, but what could we do to make it better? So we ended up buying the Caliphia 3.0 ECMO simulator and put it to use. And we wanna make these scenarios that we put them through as realistic as we can. So we do simulate a ruptured circuit, de-cannulation, things like this. And they have to react to that and talk about how would they deal with this situation? What would they do? Where would you place a clamp like you see in the picture here? Or how would you treat the patient while somebody else is taking care of the circuit? We feel like having this type of program really helps to build confidence, not just in emergencies, but also in treating patients on a day-to-day basis because if you're worried about how you're reacting in an emergency situation as you're treating these patients and you have that in the back of your mind, I think it can impact you. But if you have that confidence that you know how to handle the situation, I think that goes a long way. And our goal then is to make this a multidisciplinary approach. So we'll have teams in another room and as somebody is going through a scenario and they're presented with something, they might have to call in the perfusionist, they might have to call in the intensivist, they might have to call the cardiac surgery team in. And we wanna make that as realistic as we can then in that regard. The other thing to consider is, can you offer this type of training for those centers that you partner with? It's one thing to have this for your team and run your teams through it and that's great and you should do that. But can you also offer this for these outside centers that you partner with? I really strongly believe that by doing that, you're gonna improve patient care starting from the very beginning at that outside center instead of waiting to have that higher level of care when they get to you, you can start providing that same level of experience and you can take your experience and level of care that you know and you can put it into these centers and help them to do a better job from the very beginning. And so it's a true partnership with them. The other thing we wanna do is focus on quality. So we did pretty early on, we started a quality assurance and process improvement meeting and we would actually review every single patient that we had and we would look at what we did right, what we did wrong and how can we do it better? And having the fewer numbers at the beginning allowed us to do that. As our volume has grown, we can no longer review every single patient, we just don't have enough time. However, what we've done is we assigned the cardiac surgery fellows the task of reviewing those patients and then picking out patients now that had a special circumstance around them, maybe a moral dilemma associated with it. You know, maybe something as simple as, you know, what cane that were selected that made a difference in the outcome. And so they select these patients and then we review those few patients and try to improve our process from that. The other thing that we have done is with our staffing model is we've gone with a hybrid approach from the very beginning. We do have a perfidious in-house 24-7 for coverage. We handle the setup, the priming, initiating support. We round on the patients once per shift at least and then we're also there for any kind of emergency circuit response, transports to CT to procedure areas, things like that. The bedside nurses, after they meet minimum qualifications, they go through a four to five hour class and then they can become a level three ECMO nurse. Once they go through that program, then they are shadowed by an experienced ECMO nurse for four weeks. And then every year they have to go through annual competencies as far as the ECMO program itself goes along with the normal competencies that they have. The other thing that happened kind of just a natural evolution was the circle of caregivers that we interact with. Early on it was pretty small. You know, your typical, you know, ones that would work with an ECMO patient or any kind of extracorporeal circuit, cardiac surgeons, perfusions, the nurses, respiratory therapy, and of course the anesthesia critical care who we only had a couple at the beginning, but as our program grow, so did our circle. And so now the team that we regularly interact with is much larger as you can see here. And as a result that care just continually evolves and improves that we're providing those patients, the more of these specialties you can get involved, the better the outcome for the patient. The other thing you wanna look at is just improved equipment. You know, one of the things we did was we went from a large bulky ECMO cart like you saw from the very beginning slides to a more narrow cart. And that's just a simple thing that we did. One of the larger things we did is a nursing team and a nurse educator. They went out and decided to bring in these tilting beds so that we can place a patient on a tilting bed. And we do it pretty early on. And so those patients, even if they're primarily candulated, we can stand them up and interact with them as you could see in this video. And it's really made a big difference in these patients. You know, getting them into these different positions not just helps with, you know, the weight bearing, but also as you can imagine the anatomy and what you're dealing with, you know, with the lungs and processes are going through, you know, staying flat and prone in one position is not good for you. So getting them up and changing that position is beneficial as well. So just a simple act of standing them up like this is a big change for them and it can help with their care and improvement. But then it just also allows for different levels of interaction. It's helping them with building up their strength in their legs to be able to handle the next step and things as far as ambulation and movement through the hallways and whatnot. And then the next step for us was community outreach. We did some site visits from the very beginning but we wanted to add to that. We wanted to have education centers, consultation and transport center hotlines that we added an ECMO symposium. As I mentioned, high fidelity simulation training that we do and that we also want to offer to our community partners. And then recently we started an ECMO retrieval program. So again, you have to ask yourself, why are you partnering with outside centers? Is it just to accept patients or is it truly to improve patient care? Not just at your center, but at their center as well. So for us, we started with site visits and education centers with these outside hospitals. One of the early ones was Fairfield Medical Center that we have partnered with. We would start off by having them come in. We'd have the welcome and greeting that we would normally do and provide them with some food. It's always a good way to start. And then we do like an ECMO overview. Early on, it would be like an hour long talk that somebody would give. And what we found it's more effective to break that up into like three smaller sessions. You hit a key typical ECMO points that you need to those topics, but then also hit on something that's more of a topic of the day. Like right now would be COVID. And then from there, we would go up and we do a mock ECMO insertion along with transport to the ICU and a handoff. After that was completed, we would then break up into our peer groups and we would round on the patients since we're already in the ICU. It worked very well. And breaking up into those peer groups, I allow you to have that more intimate one-on-one conversations with your peers about how you personally handle things and how your team personally handles things versus how you handle things as a overall team. And then at the end, we come back together and we have a debrief and we have a question and answer session. We found these to be very effective. The other thing we did is we've always had a transfer hotline for centers to call, but what we wanted to add was a consultation line for ECMO. And so we created the ECMO patient consultation with just 293 ECMO. Very easy for people to remember. And the thing I really like about this is from the beginning, it wasn't simply about them calling us about taking their ECMO patients. It was about calling us to help them improve care at their site. So when they call us, it's not just, yep, use these cannulas in this circuit and get them on ECMO. Have you tried this treatment method? Have you tried this one? You might go to avoid placing this patient on ECMO or they might just simply say, we really don't think that this patient needs ECMO. And so it's really helped these outside centers in refining their process at their site on whether or not to place patients on ECMO. And then, of course, there is that call that they'll come and they've placed a patient on ECMO. How can we manage that patient better? What should we be looking for until we can arrange transportation to our center? So it's been a very beneficial tool that a lot of the community partners have given us good feedback on. Another thing that we wanted to do was host an ECMO symposium. We put this together pretty quick. The lady picture with me on the left is Ellen Yokohama and she was so instrumental in putting this together. She helps a lot of the different groups in doing this. And so we could have never done it without her. And the other picture is Venus Atapria and Brian Whitson who are ECMO directors at the time. And so we had this vision with this symposium that we were hoping to reach about 50 participants from maybe six or 10 centers. And we thought that that would have a meaningful impact in the community by getting some of the experiences that we've had and some of the knowledge that we've gained and putting that out into community, like I said before. When it actually came time as we got closer to the symposium, what we actually found was that we ended up with 165 people registered from 22 different centers and everybody attended. And I don't say this to talk about, what a great symposium we put on and how popular it was. Instead, it's to highlight the fact that there was a real thirst for this type of knowledge in the community. And so we saw a role that we needed to step into in this regard. The latest thing that we've done is we've launched an ECMO retrieval program. We actually went through the first 10 years with people delivering ECMO to us, but especially with COVID, what we found was, these resources at these smaller centers was strained in doing that. And so we wanted to answer that need in the community. And so we started our ECMO retrieval program. I'm proud to say we partnered with MedFlight who's just an amazing and professional team. And so from the beginning, what we did is we had classes and we had sessions where we got together with them and we would bring up a gurney from the mobile ICU, have a dummy in the unit that we would go to retrieve. And so we'd go through the process of all the steps that's involved in retrieving this patient and what you have to watch for in moving them over onto the gurney and then the checklist that you go through before departing and then transport them back downstairs to the mobile ICU and load them up to head back to OSU for the training. And I'm proud to say that after launching the program on February 1st, we actually had our first activation on February 3rd. The young man you see in this picture in scrubs is Greg Davis. He was day three on the job. And we did not just throw him to the wolves and send him out on the ECMO retrieval on day three. He actually went with Jim Ralston, who's been at Ohio State for 33 years. And so he had this great pairing of a young eager guy that came from the center of the ECMO transports going along with the experienced guide OSU who hadn't. And so it was a really nice pairing and it worked really well. And I was proud to say that after bringing this gentleman back that we were able to provide him with that next level of support that he needed. And so our growth over the years, after the ECMO symposium, we did see an increase in partnerships and relationships formed. Some of them was just conversations. Some of them were true partnerships where people wanted to start a program or they had recently started a program. Early on it was Mount Carmel and Fairfield were the ones that we primarily received patients from. We started partnering with these other centers that you see here on the slide. And then of course our growth, our program growth occurred along with that. So in 2015, you can see with this outreach program that our growth didn't improve and grow. Got a little bit of a drop in 2016, but then from 2017 on, we've been right at about 100 patients per year. So far in 2021, we've already done 51 ECMOs in the first 90 days. The other really neat thing that just kind of happened and evolved as a result of a program where you're investing into your partnerships is that people talk about it. And so early on, it was pretty much just in Ohio. And honestly, it was inside the outer belt of 270 in Columbus, Ohio. But that started to grow and we started to partner with people outside of the outer belt and in different areas in Ohio. And then from there, it just continued to grow where people were reaching out to us from the Midwest region and from there it just grew and it continued to grow until finally we had this national footprint where people had called to us and asked about how we run a program, different ways that we staff things and such. And so it's been a really neat experience. Like I said, in the one slide, that our circle within Ohio State had grown from that small little group to a much larger group. And now what we've seen is we've started to have these interactions with different centers across the country. And it's just been a great thing to see evolve. And then of course, everybody's been dealing with the COVID pandemic. And so I did wanna touch a little bit about how we managed our team during the pandemic and what we went through during that. So we have a team of 14 full-time and two part-time staff. And one of the things that we were looking at in terms of staffing was how do we reduce the impact of a team member to test positive? So we split them up into two teams. And the goal was at the beginning was to rotate two weeks on and two weeks off. And the idea behind that was that it would allow for time for symptoms to develop, right? So if somebody got exposed, then during their time off, then they would have that two-week period to develop those symptoms. And then hopefully we could avoid them coming back in and exposing somebody else. Our leadership team actually ended up reducing that to one week on and one week off. And it was the right call. What we found out was that most symptoms develop within five to seven days. So the chance of that, somebody getting exposed as a result was pretty low. And then the nice thing about the one week on, one week off is it actually reduced the strain on the teams. As you can imagine, anybody that worked in a COVID unit two weeks on, two weeks off is a long way to go. There were other teams that certainly went longer than that. But this one week on, one week off model really worked well for us. They called it the bullpen model. And so for us, all of our cardiac related COVID patients and some others even went to one unit in the Ross Hart hospital where we work. And so that unit, it was really interesting to see because what happened was we have a partnership with the prison system in Ohio. And so as those patients came in to our floor, we had a lot of prisoners and a lot of guards on the same floor together. And there was a lot of concern about that. And so they actually ended up bringing in a national guard and they had a national guard, national guardsman stationed in our unit and around the area just because of how many prisoners and guards we had on one unit together. And so it just added this whole another layer of surrealness. So when you walk down onto the floor and everybody's in their COVID gear and all the PPE, and then you have these armed guards and their PPE there. And as well as prison guards sitting outside of some of the patient rooms, it just was a surreal experience to go through. But the team rallied together really well and did a great job supporting the patients. So for us during our first wave, we had about 150 patients in house at one time. I think we went just over 150. We had about six to eight patients on ECMO at any given time and the majority of these were COVID positive patients. However, during the second wave, it was a little bit different. We actually had more patients in house over 200. But we'd see about the same number of six to eight patients on ECMO at any one time. And the reason for this was that our teams had really learned how to treat these patients in a better way than what that first wave when really nobody knew how to treat these patients and what was the best path to take for them. And so as we got better and caring for these patients then we were able to avoid ECMO. Again, it's not always about just getting a patient on ECMO. So we're able to avoid ECMO on some of these. And so we saw a different mix in the next time around where we did have some COVID positive patients but we also had to oppose COVID patients and of course your typical ECMO patients that you normally support. In Ohio, they divided Ohio into four zones. And so any patient in a given zone would go to a tertiary hospital and we were that hospital in zone two in Ohio. And so we did get some transfers as a result that way. And then I wanna talk about operational challenges of just having an ECMO program and what you're utilizing. As you know, any foreign surface presents challenges with clot formation. The question is, does the design of what you're using reduce or increase the likelihood of that happening? We know there has to be a need for external monitoring on some systems with the saturations, pressures, temperatures and such. And I consider that like a necessary evil because it adds clutter to the system. And I'll talk a little bit more about that here in a minute. But for us, we were looking for a solution that reduced the likelihood of thrombus formation. And then hopefully as a result reduce the oxygenary changeouts, staff exposure to the blood, risk to the patients and such that goes along with that. And then we're hoping to find that integrated monitoring for a cleaner circuit. And so when Medtronic and MC3 approached us about this novelist, we jumped at the opportunity. You know the old saying a square peg does not fit in a round hole. Well, having this round design fits with what we see in a patient's vasculature, fits with what we see in our own circuits that we use. And so it's just that natural design that you would expect. It does have the same transverse flow path that we like that has that lower pressure drop. It has a minimal surface contact. But that circular profile I think really makes a difference. And it's not just the circular profile of the membrane itself, but it's the design changes on the inflow and the outflow. As you look at it here, you'll see the inflow is actually lower than the outflow. And that allows the blood as it comes in to pass up across the membrane's face. And it has filling veins that then help with the spread out across the entire face. So you hopefully get that more even crossing of blood across the membrane. And so that reduces the velocity of blood going across right at the lower portion of the oxygenator, maybe leaving some areas of stasis. And those filling veins, again, help it spread out so you get that whole distribution across the face. And then you have the interactive display. That touchscreen is really nice. You see all the different parameters that are monitored here. You got the inlet pressure, the outlet pressure, and the inlet saturation and outlet saturation along with the temperature. And then you got the delta P between the two pressures. All of these, you can touch the parameter that's showing and it will bring up the menu underneath it that has the different parameters that you can set for the alarms. So you determine what your high alarm limit is, what your low alarm limit is. And then in the center of the screen, you have the saturation calibration button that you can hit to store values and then calibrate the saturation and then put in a hematocrit range that it's within. And so it's a really nice and simple system. It's actually very intuitive to use. If I didn't give you a class on this and I just gave this to the average profusers, they would be able to go in here and figure this screen out in no time at all. What I really like about it is along with this interactive touchscreen that's very intuitive to use is you have that same performance predictability. You have that, we have a simplified circuit now which has allowed us to streamline our workflow. And what I mean is that without the extra lines and saturation lines and temperature lines and whatnot is it allows you to streamline that workflow. You don't have to add all these things to it as you're building it. And so the priming process is actually much faster. And then you do have that performance durability. So for us, I really think this picture does a lot. It really speaks a lot to how our circuit has changed in utilizing the smart Nautilus. So we have a cleaner system. When it comes to having a cleaner system, think about transporting a patient to CT through those crowded hallways or ambulating a patient around a unit and going in and out of the different things that are sitting in the unit. Personally, I would rather do it with a cleaner circuit than with a cluttered circuit. And so when you look at it, the one on the left and the equipment that we've been able to get rid of the saturation monitor is gone along with the fiber optic cables which have a mind of their own and like to stick out and grab things. And then the cells that they connect to which reduces a connector in a circuit which is always a good thing. We were able to reduce or I'm sorry, remove our recirculation line that we'd run off the top of the oxygenator and then back pre-pump so that we could help reduce stasis there. And we're able to reduce the pressure monitoring the pressure dome and pressure lines that we had on it as well since all that is now integrated into the oxygenator itself. And so when you look at the one on the right versus one on the left, it's a much cleaner system. One that I feel more comfortable transporting through the hallways in the hospital. The other thing is the indicator bar. It does give you that assurance at a glance. The status bar was not a feature that swayed us when we were looking at it. In fact, I didn't give it a second thought when they talked about it but after we had used it especially during the COVID pandemic during the worst part of it and talking to some of the nurses and intensivists on the floor some of them reflected about how when they would walk by a room and they look in and they see that green glow just gave them that assurance at a glance that this wasn't a patient that they had to worry about right then. Yeah, sure they're gonna come back and they're gonna round on that patient and take care of that patient. But when you were going from one fire to another putting them out going by a room and seeing that green glow knowing that all the parameters are within those that you said was actually reassuring to them. So I actually turned into a nice little extra positive that I didn't expect. And so now that I've told you about the status bar and what that's meant to the team I didn't want to kind of walk you through the slide and some of the things that we've experienced while using the Nautilus. So what you see here is actually the ready screen. We like to use a ready screen when we're getting ready to initiate ECMO with the Nautilus. And what this does is it allows you to see all the parameters underneath the screen that are active at the time but they won't be alarming. So when you're getting ready to initiate you don't want those alarms active and have it going off. And so this is a way that you can still see what's going on with the oxygenator but you don't necessarily have those active alarms. Once we initiate you simply press and hold the play button that you see there for about three seconds and that will activate the screen and then activate all the alarms in their preset mode. This is a typical screen that you would see during normal operation. And one of the nice things is when it comes to these pressures there is no going in and having to zero them. They come pre-zero from the factory and they stay that way. And so this delta P that you're seeing here this has been a very typical delta P that we have seen. In fact, a lot of times at initiation we see it even lower than this. And honestly I can't recall yet seeing a delta P over 30. The other thing you'll notice is in the bottom left hand corner you have the auto rotate screen. So when you press that button it will automatically flip the screen. So depending on which side you're looking at it from you can change that. And then even in the bottom center it's showing that right now that this oxygenator is plugged in to the wall power. However, if you're going to be ambulating transporting the CT to the OR or whatever you might be doing when you unplug it from the wall then you'll see that battery indicator light up and it does alert you if you get down to 25% of battery life and it will have that yellow that status bar will change to a yellow status bar in that situation. And this is an example of an oxygenator with that alert going off. So in this situation the status bar that's yellow will be flashing and then the parameter that's affected will also be lit up and you'll have an audible alarm. And this is a nice bright indicator light. So you can actually see this from across the room even out at the nurse's station if somebody had stepped out for some reason. And this one's really easy to diagnose. You got a low outlet saturation. And as you can see right to the right on the right side of the screen is the oxygen line has been disconnected. So let's say you're ambulating the patient and somehow that gets bumped and disconnected and you're gonna have that alert right away that something's not right here. And it's good that during ambulation with that battery backup that you do maintain the saturations of the pressures of temperatures all the parameters that you're monitoring you don't lose any of that during ambulation or transport. And then finally I just wanted to show you a screen where that one of those parameter windows is opened up and in this situation we are weaning the patient. And so as the saturations, as you're coming down the FI-2 the saturations are dropping you wanna be able to go in and change that lower parameter limit so that that alarm's not constantly going off. And so we also found that very beneficial. And then as far as our experience with the Nautilus so far we have supported 24 patients to date. Our longest duration of support was 21 days. Our shortest duration of support was just four days. And that gives us an average of about 9.75 days or almost 10 days. We have changed out two Nautilus. One was due to a suspected gas transfer by the clinical team. However, the new oxygenator that was changed out to did not improve performance and investigation did determine that the oxygenator was functioning normally. We also did change out one Nautilus for thrombus buildup. Like I said, it doesn't matter what the foreign surfaces eventually you're gonna have thrombus buildup. And in this case, it was a VVECMO patient who was not on Heparin throughout the duration of the support. And after 14 days on support we did have that increasing thrombus formation on the oxygenator. It should be noted when we drew a pre and post gas it was functioning properly. So it did have a PO2 greater than 300 saturation was a hundred percent still. But what we were seeing was that the lactate was steadily increasing and had gone up several hundred just over the course of a couple of days. So the decision was made to change out that oxygenator in that case. One thing I'd like to add is when you have a major ECMO program especially or really any ECMO program it's really important to recognize the staff. This is a very labor intensive and resource intensive modality that's being offered to these patients. And so taking the time to recognize them is very important. What you see here was a slide that we had that we used during a 10 year recognition lunch and that we did for the team. And we really made it a point to highlight a lot of the different team members and people who have contributed to the program over the years. And we also made sure to highlight those patients that have been really good success stories. Any ECMO program is going to have some rough bumps along the way. Some of those bad outcomes that you don't want to have but they're unavoidable. So it's really important to some of those saves that you really had that were really just amazing saves. It's really important to highlight those and remind people just what it is that you're doing. So before our reaction was kind of like that young child turning around running back out when someone would mention ECMO what would be our reaction now? It's actually more something like this. This isn't to say that we're some sort of superhero program that we're some sort of superhero ECMO institution. It's just that before when we were unsure and uncertain and we didn't want anything to do with ECMO now we actually have that confidence. We actually have that skill set that we know that we can go into any patient situation whether they're getting chest compressions or whether it's just an emergent placement of some sort, we can go in there and we can actually successfully place ECMO in these patients and we have that confidence that we're going to be able to do so with the team that we have around us. And so with that I just want to say thank you and go Bucks.