Qatar Medical Journal - 1 - Extracorporeal Life Support Organisation of the South and West Asia Chapter 2017 Conference Proceedings, February 2017

Background: Obesity, defined according to body mass index (BMI > 30 kg/m²), is an increasing problem in the world's population. The proportion of extremely obese patients (BMI > 40 kg/m²) in intensive care units varies between 2.8 and 6.8%.¹ A BMI higher than 40 kg/m² seems to be associated with an increased risk of developing acute respiratory distress syndrome (ARDS) along with greater morbidity, length of stay, and duration of mechanical ventilation in the intensive care unit (ICU).²

The use of veno-venous extracorporeal membrane oxygenation (ECMO) has reemerged as an option for acute respiratory distress syndrome (ARDS) refractory to conventional support.³ In addition to cannulation difficulty, morbid obesity can pose a significant challenge to obtaining sufficient circuit flow, indexed to either weight or body surface area (BSA), required to sustain lung rest and recovery.⁴ Owing to this hypothetical obstacle, there remains significant hesitancy in many centers to offer ECMO support to this patient population. However, Zachary N and his colleague in 2015 proved the efficacy of veno-venous ECMO in this patient population.⁵Methods: In King Fahd Jeddah ECMO center, Patients requiring ECMO for ARDS between April 2014 and May 2016 were reviewed retrospectively with institutional review board approval. Demographics, ECMO variables, and outcomes were assessed. Obesity, morbid obesity, and super obesity were defined as a body mass index (BMI) greater than 30 kg/m², greater than 40 kg/m², and greater than 50 kg/m², respectively. Results: Forty-nine patients (36M/13F) with ARDS were placed on ECMO during the study period. Fifteen were obese with a BMI of 32.7 kg/m² (interquartile range [IQR]: 31.6–34.9 kg/m²). Four were morbidly obese with a BMI of 46 kg/m² (IQR: 43.5–48.5 kg/m²). Nine were super morbidly obese with a BMI of 59 kg/m² (IQR: 54.5–69.5 kg/m²). Pre-ECMO mechanical ventilator support and indices of disease severity were similar between the three groups, as were the cannulation strategy and the duration of ECMO support.

The 90-day survival rate was 71% (20/28) in patients with a BMI more than 30 kg/m² compared with 42% (9/21) in the non-obese group. Subgroup analysis showed improved survival in morbidly obese patients as 75% (3/4), and super morbidly obese patients as 88.8% (8/9). There were four bleeding complications, two in each morbidly and super morbidly obese group. Conclusions: ECMO in obese patients is feasible and life-saving. Therefore, a percutaneous cannulation remains feasible. The goals of the ECMO therapy include early spontaneous breathing, tracheotomy, rapid reduction of sedation, and adequate analgesia.

Interstitial lung disease comprises a heterogeneous group of histologically distinct pathological entities characterized by a diffuse inflammatory process affecting the lung parenchyma. Classification of interstitial lung disease is complex and usually determined by a combination of clinical features, radiological, particularly computed tomography, appearance, and findings at lung biopsy. Interstitial lung disease presentations can range from slowly progressive interstitial pneumonitis to more rapidly progressive vasculitic, eosinophilic, and acute fibrotic diseases. In the acute form, interstitial lung disease can, over a period of days, manifest as bilateral diffuse pulmonary infiltrates, causing a significant disturbance of respiratory function. Patients characteristically have very poor dynamic compliance and poor gas exchange. The outcome of patients with interstitial lung disease admitted to the Intensive Care Unit (ICU) has historically been very poor. This is thought to be a combination of both the lack of reversibility of the underlying respiratory problem and further damage to the lungs associated with necessarily invasive mechanical ventilation.^1–3 The pro-inflammatory effects of invasive ventilation have been well described and are proportional to both tidal ventilation and pressure within the lung. There are a number of potential treatment options now available, which may help to modify the course of the disease,⁴ particularly in cases where there is a very high level of inflammation within the lung. Treatment options currently available include high-dose steroids, rituximab, and cyclophosphamide. Recently patients with acute interstitial lung disease have been offered extracorporeal membrane oxygenation (ECMO) as both a life-sustaining supportive therapy and a means of avoiding ventilator-induced lung injury, and results are improving, particularly in patients with acute interstitial lung disease.⁵ One of the benefits of ECMO is that it can allow patients to be awake and undertake physical and pulmonary rehabilitation.⁶ This may be of particular benefit in the interstitial lung disease population, where a bridge to transplant is being considered. The latest evidence for the use of ECMO in interstitial lung disease will be reviewed, including clinical phenotypes which appear to particularly benefit from ECMO as a bridge to recovery. Some patients who present with what is assumed to be an infective pneumonia will ultimately progress to developing a progressive acute interstitial lung disease and it is essential to differentiate such patients from those with acute respiratory distress syndrome. In patients with acute interstitial lung disease, there are treatments which may modify the course of the disease, whereas the predominant management of acute respiratory distress syndrome is largely avoiding lung inflammation to prevent the progression. A strategy for investigation and the key clinical and physiological indicators of potential acute interstitial lung disease will be discussed.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in adult patients with either cardiac or respiratory failure or both in many settings.^1,2 This includes pregnant patients and those who are postpartum experiencing cardiac or respiratory failure, a particularly vulnerable population where both the mother and the fetus are at risk.

There is scant literature addressing the use of ECMO for either cardiac or respiratory failure in patients who are pregnant or postpartum. However, there are many potential indications, such as the acute respiratory distress syndrome (due to pneumonia, especially influenza pneumonia; aspiration; transfusion-related lung injury; or non-pulmonary sepsis), pulmonary embolism, amniotic fluid embolism, management of pre-existing or newly diagnosed pulmonary hypertension, cardiomyopathy (including postpartum cardiomyopathy), extracorporeal cardiopulmonary resuscitation (most frequently in the setting of pulmonary embolism or amniotic fluid embolism), and other conditions that are less commonly seen in the pregnant and peripartum patient population, which nevertheless may be encountered by clinicians.

Case reports and case series are beginning to illuminate the management of such patients and suggest that ECMO in this setting may be beneficial to save the lives of both the mother and child. A case series of four patients reported survival in all four mothers and in three of the four fetuses.³ The largest case series in the literature reported on 18 peripartum patients, four of whom were pregnant at the time of cannulation.⁴ Mortality in that series was 11.1% with only two patients not surviving to hospital discharge. Fetal survival was 100% in those patients cannulated after fetal viability – overall fetal survival was 77.8%. One-third of the patients in this cohort had bleeding as a complication of their ECMO with no fetal complications attributable to ECMO. Other complications in the mothers included: DIC, as well as occlusive and non-occlusive deep vein thromboses. The risk of complications must be weighed against any potential benefits of using ECMO in these patients. A subset of patients were able to participate in active physical therapy while receiving ECMO (38.9%), with four patients being able to ambulate around the intensive care unit while receiving ECMO. The duration of ECMO was relatively brief overall (median 6.6 days), which was similar in both of these series.^3,4

While ECMO appears from case reports and case series to be both feasible and reasonably safe in patients who are pregnant or postpartum with cardiac or respiratory failure, more data are clearly needed to better appreciate the potential indications, contraindications, and specific techniques involved. However, given the potential for recovery in a population that skews younger and healthier than the general population, deploying ECMO, even in severely critically ill patients in this setting, may be appropriate in centers experienced with the use of ECMO for cardiac and respiratory failure. For centers that do not have this experience, early referral is encouraged in those cases where deterioration may be anticipated.

Pulmonary vasculitis is a rare disease that typically shows inflammation in pulmonary vessel walls and necrosis.¹ The disease is usually immune mediated, common in young patients, triggered by many factors, and with wide clinical and radiologic presentations. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAVs) is the main focus in most literature and includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), Churg–Strauss syndrome (CSS), idiopathic pauci immune pulmonary capillaritis (IPIPC), secondary to systemic lupus erythematosus, and other types like anti-glomerular basement membrane disease, drug-induced vasculitis after cannabis and glue inhalation.² Diagnosis is usually established after careful history taking clinical, radiologic, and laboratory evidence; bilateral lung infiltrates with or without pulmonary hemorrhages and peripheral distribution, positive ANCA-P component, proteinase-3 ELISA test, anti-glomerular basement membrane antibody, and other antibodies associated with immunologic disease like systemic lupus erythematosus. Sometimes, lung biopsy may be needed but because of the low yield of bronchoscopic biopsies and the need for open lung biopsy, this tool is rarely used specially in critically ill patients. Treatment is by the use of steroids and cytotoxic medications like cyclophosphamide and mycophenolate mofetil. In refractory cases, plasmapheresis or the monoclonal antibody rituximab may be used. Pulmonary hemorrhage is a common manifestation in vasculitic lung syndromes; however, many other disease and toxins can trigger pulmonary hemorrhage, which can be life threatening.³ The diagnosis of pulmonary hemorrhage is generally considered based on clinical and radiological findings and is characterized by acute bilateral patchy lung infiltrates more centrally located but may be diffuse. Sequential aliquots of bronchoalveolar lavage yield progressively bloodier return and help in diagnosis.⁴ Treatment depends largely on the cause. Extracorporeal membrane oxygenation (ECMO) is a life support modality that can be used in severe cases of pulmonary vasculitis and hemorrhage with great caution and careful assessment of risk of bleeding with anticoagulation and benefit of use as life-saving support. With newer ECMO circuits used (either heparin- or bioline-coated circuits), several days of heparin-free ECMO runs may be successful. In some reported cases, citrate was used as an anticoagulant.⁵ The ECMO modality shall be carefully chosen especially in the presence of pulmonary hypertension, which may affect the veno-venous (VV) ECMO flow, and hence, echocardiographic assessment before initiation is mandatory to avoid low-efficiency runs. In cases with severe pulmonary hypertension, veno-arterial (VA) ECMO would be more suitable. Institution of treatment using steroids and cytotoxic drugs in addition to plasmapheresis is warranted upon suspected diagnosis. The rapid initiation of treatment may be the key point of survival in such cases. There are some case reports where plasmapheresis and immunosuppressive therapies were used based on clinical and radiographic data alone⁵ with successful outcome. There is paucity of data regarding drug doses of immunosuppressive drugs used during the ECMO run, and the duration of treatment was variable. Most of the cases reported started with 1 g of methylprednisolone for 3 days followed by either plasmapheresis and cyclophosphamide or cyclophosphamide and rituximab.⁶ The plasmapheresis circuit installation needs to be addressed whether to be incorporated into the ECMO circuit⁷ or not.

Pulmonary infection and respiratory failure are the most common causes of admission to the intensive care unit (ICU) in human immunodeficiency virus (HIV)-positive patients.^1,2

In our experience, in a developing nation (despite the advent of HAART), the commonest cause of admission to ICU and mechanical ventilation still remains Pneumocystis jiroveci pneumonia (PJP). Most of these patients presenting with PJP have not been on antiretroviral therapy (ART) or been treated with PJP prophylaxis, and it is highly likely that this is their first time presentation to hospital.³ The advent of highly active antiretroviral therapy (HAART) has allowed for more effective treatment of HIV-positive patients; however, despite this, PJP remains the most common acquired immunodeficiency syndrome (AIDS)-defining condition and is associated with much morbidity and mortality, in both developing and developed nations.⁴ In developed countries, mortality may reach up to 85%, while, in developing countries, the mortality figure nears 100%.^3,5 In consideration of the above mortality figures, it may be said that conventional mechanical ventilation (CMV) has failed to improve outcomes (and reduce morbidity) in HIV-positive patients who present with severe acute respiratory failure (ARF), especially in cases caused by PJP.

This has opened the door to using extracorporeal membrane oxygenation (ECMO) as a treatment modality. We found that ECMO was used with good success in treating these patients, with a much improved survival rate (see Table 1). Most of our patients were newly diagnosed HIV positive, and were not on HAART at the time of admission. HAART was immediately initiated in the ICU once the HIV diagnosis was made. We found a 68% overall survival of our HIV-positive patients who received ECMO treatment and a 61% survival of the PJP subset of patients. Of note is the median duration of ventilation required: 9 days. This is significantly shorter than our pre-ECMO experience in severe ARDS PJP patients (p = 0.020), where most patients were ventilated for significantly longer than 9 days. Also noteworthy is that the median duration of ECMO was 9.5 days.

While on ECMO, we identified two factors that were clearly associated with poor outcomes in our series of patients with PJP:

[1]  Duration of ECMO. Patients who survived had an ECMO run of 7 days on average and those who died were on ECMO for >13 days; [2]  The need for inotropic support while on ECMO was a strong predictor of mortality.

We found that CD4 count was not a predictor of mortality.

This suggests that ECMO is a viable and effective treatment for HIV-positive patients who present with severe ARDS.

Congenital diaphragmatic hernia (CDH) remains a common defect in infants and occurs worldwide at a rate of 0.8–4.5 per 10,000 live births. It is associated with high mortality and morbidity. Veno-arterial (VA) support remains common in neonates with CDH, although venovenous support has also been used.¹ Criteria for extracorporeal membrane oxygenation (ECMO) in CDH patients remain an inexact science. Studies have evaluated the role of achievable gas exchange (both carbon dioxide and oxygen), fetal lung-to-head ratio, lung volume estimates, and other factors in predicting outcomes, but none have proven to be highly accurate.² Currently, observed/expected lung-to-head ratio of < 1 and liver position up in chest are associated with poor outcomes in some reports. Fetal therapies to encourage lung growth with tracheal occlusion are also occurring in cases of predicted severe CDH. Following birth, use of “gentle” ventilation is recommended to limit mechanical ventilator-induced lung injury. Use of inhaled nitric oxide to alleviate pulmonary hypertension may be helpful in some patients as well. High-frequency oscillatory ventilation is often provided. If the patient remains unstable or has severe hypercarbia or hypoxia, ECMO is considered. Despite many years of experience with CDH and ECMO, it should be noted that survival remains only about 50% and has not markedly improved over time.³ There is little consensus on when to repair the CDH, with some clinicians performing surgery while on ECMO and others preferring that the patient be weaned off ECMO successfully prior to surgical hernia repair.⁴ Survivors often have residual problems such as frequent respiratory illnesses that bring them into the hospital even after they get successfully discharged. Coexistent cardiac or genetic abnormalities have also been associated with poor outcome in patients with CDH, with or without ECMO support.⁵ CDH care is also expensive, especially in patients who require ECMO or prolonged hospital stays. It is hoped that future research will result in improvements in prevention and treatment for these fragile infants. Until that time, ECMO will continue to hold a place in support of these patients.

Extracorporeal membrane oxygenation (ECMO) is an increasingly used life support modality in both respiratory and cardiac cases. The ECMO run may last from a few hours to several months and is usually associated with many major and minor events that can be overseen and may not always be documented. These ECMO complications are related to the circuit, the patient, or other factors such as procedures, drugs, environment, and personnel. The circuit may show some events that are usually predictable, manageable but require training to be dealt with effectively without compromising patient safety. Fortunately, the circuit-related complications are the most documented,¹ which include: oxygenator failure, clotting, inflammatory response, disseminated intravascular coagulopathy, thrombopenia, hemolysis, air embolism, cannula-related blood stream infections, cannula dislodgement, bleeding, injury during insertion, malpositioning, recirculation, hypothermia, chattering, and oxygenator malfunction. The commonest complications include the oxygenator failure (occurs in 10% of ECMO runs), infections (reported in 17% of ECMO runs), and cannula-related problems (present in 19–20% of ECMO runs in one form or another).¹ Patient-related complications include: neurologic complications including hemorrhages or strokes, infections, bed sores due to prolonged recumbency, deep vein thrombosis and subsequent pulmonary embolism, limb ischemia, sepsis and septic shock, acute kidney injury, pneumothorax and pneumomediastinum, psychological complications, musculoskeletal weakness, and hemolysis.¹ Procedures-related complications include pneumothorax, surgical emphysema, catheter-related complications, and others. Drug-related issues include hemorrhage from anticoagulation, acute kidney injury from antibiotics, heparin-induced thrombocytopenia,^2–4 some other iatrogenic incidents related to the staff, equipment, and facility (environment), which may include transport-related complications, electricity-related events, and medical gases-related events, and these are usually unexpected and require special skills in communication and management.^5,6 These complications may represent a major distress to the patient, caring medical team, and family members. Proper training, adequate preparation in anticipation of potential issues, and team work are the key and only way to handle these complications.⁷ Among other nightmares are ethical and legal considerations about the end of life that are still a major area of debate especially in countries without transplantation programs and clear legalization to support withdrawal.⁸ In summary, nightmares during ECMO runs may occur, and hence, they should be expected. Complications and incidents may occur at any point in time during ECMO runs, and hence, careful and continuous monitoring and regular staff training to manage these complications are the key principles for safe daily ECMO practice.

With the introduction of veno-venous extracorporeal membrane oxygenation (VV-ECMO) to Qatar, the medical intensive care unit (MICU) team started to face new and challenging ethical dilemmas. These ethical questions have subjected the team of physicians, nurses, and other healthcare professionals to mental stress in addition to the physical stress already encountered running the ECMO service.

In this article, we reviewed the literature for similar ethical dilemmas to the ones we have faced comparing our experience with that of other centers around the world.¹

The main principles that we applied were justice, beneficence, non-maleficence, and avoiding cruelty.² The principle of justice was practiced by making ECMO service available to all residents of Qatar, regardless of their social, cultural, or economic background.

Applying this principle has not incurred any injustice to the other fields of medicine as the health system in Qatar provides full medical coverage to all residents of Qatar. The principle of beneficence was applied by lowering the threshold of accepting acute respiratory distress syndrome (ARDS) cases regardless of the inciting cause. As such, ECMO support was started for patients with ARDS due to medical, surgical, and trauma-related conditions.

The two principles of non-maleficence and avoiding cruelty were most challenging.³ The team faced these two principles when dealing with a patient who ended with permanently damaged lungs due to open TB and ARDS with no favorable outcome; lung transplantation was not available in Qatar. What made the situation difficult was the fact that the patient was alert, communicating, and able to make decisions. The patient clearly indicated wanting to stay on ECMO support to stay alive, hoping to return home. Although some argued against continuing ECMO to avoid complications which will harm the patient, others argued against stopping ECMO as it would lead to death. As there was a clear conflict among the team members, the Ethics Committee was consulted and more than one meeting were conducted. At the end, the decision was to continue with full ECMO support, including changing the circuit and/or membrane if needed. The patient eventually succumbed to acute severe right heart failure after more than 9 months on ECMO support.

In conclusion, the ethical challenges that we faced and will most likely continue to face in the ECMO program in Qatar are similar to those faced in other parts of the world. The main difference remains that withdrawing care from futile cases is not accepted in general. This is governed by the local cultural, religious backgrounds, and the level of awareness among the medical staff and the public at large. We believe that any ECMO program should include in its training discussions about potential ethical dilemmas that will most likely be faced in the course of managing the critically ill patients.

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) provides the respiratory support in acute severe respiratory failure until the underlying acute lung pathology improves.^1,2 VV-ECMO support for >100 days is rare and in most situations requires a destination therapy of lung transplant.^3,4 This may not be an option in some centers. We had our longest ECMO case of >300 days with severe residual fibrotic lung disease and inability to wean off ECMO. This presentation briefly discusses the multifaceted challenges and lessons learned from this experience. Discussion/lessons learned: Prolonged ECMO can lead to various challenges, some of which are briefly described below.

1. General ECMO-related issues: These are more common due to prolonged ECMO run and include membrane failure, thrombosis, DIC, etc. Right ventricular failure may prove to be a terminal event in these patients.

2. Rare ECMO-related issues: Prolonged heparin therapy may lead to osteoporosis and heparin-induced thrombocytopenia (HIT). Our patient had positive HIT and was managed with prolonged argatroban therapy.

3. Unusual complications: Extensive fibrocavitary lung disease can lead to large lung cavities impairing gas exchange. Percutaneous pleuropulmonary procedures are at high risk during ECMO. We performed percutaneous drainage of a large bullous lesion without any untoward event. Unexpected hypoglycemia and type II lactic acidosis were also unusual events in our patient. Potential etiologies and management of these rare events will be discussed during the presentation.

4. Team morale and psychosocial support: Prolonged ECMO patient care with no destination therapy can be extremely stressful for care givers. Frequent debriefing sessions may help to mitigate these issues. Formal personal psychological support should be readily available to all team members to mitigate stress-related complications.

5. Skin integrity and musculoskeletal function: Besides the adequate nutrition, mobility and muscle exercises are extremely important to maintain musculoskeletal functional status. We were actively mobilizing our patient while on ECMO to prevent these complications.

6. Psychosocial issues for the patient: Prolonged ECMO, ICU stay, limited mobility, and limited family connections are a rich recipe for depression and other psychosocial issues. Team members from patient's country, birthday and other celebrations, involvement of embassy staff, and use of social media to communicate with the family back home may help to mitigate some of these issues.

7. Ethical and other considerations: ECMO to “nowhere” creates tension among the team members due to different views about the ongoing care of these patients.⁵ Consideration of withdrawal of care is a major ethical issue and needs to be resolved by involvement of all team members, local ethics committee, religious scholars' input, consideration of local policies, and input from the patient and any available family members.

8. ECMO to “nowhere” to “somewhere”: Exploration for non-regional transplant centers and resolution of financial constraints by support from the local embassy, social services support, hospital administration, charitable organization, and conducting fund-raising activities. Conclusion: Prolonged ECMO therapy poses its unique challenges. Good team dynamics, frequent debriefing sessions, and ethic consultations are extremely important during care of these patients. Innovative solutions and collaboration with regional and distant transplant centers may provide an opportunity for destination therapy in these patients.

Aim: Extracorporeal membrane oxygenation (ECMO) may be lifesaving for patients with severe cardiac/respiratory failure. Typically, ECMO is provided by specialized or regional centers, and patients may have to be transported by road or air ambulance. Herein, we will review the essential requirements for road transport of adult ECMO patients, also known as “mobile ECMO”. Background: Interfacility transport on ECMO is defined as “primary” where the ECMO team cannulates the patient at the referring facility and subsequently transports the patient to the ECMO center. In “secondary” transport, the patient is already on ECMO support at the referring facility but a need to transfer to another center has arisen.¹ Patient safety is the overriding priority in any mode of transport; however, in primary transports there is also a need to expedite the arrival of the ECMO team.¹

Interhospital transfer of critically ill patients on multi-modal organ support can be hazardous and adherence to protocols is recommended.^2,3 ECMO patients represent the extreme condition of pathophysiology and therefore meticulous planning, competent personnel, checklists, and attention to details are necessary for ensuring patient safety. Mobile ECMO team: The team composition and specific roles vary considerably between centers. There is no consensus on the exact composition or number of the members. An ECMO nurse or physician can be trained to prime the circuit. Some centers do not include a respiratory therapist (RT) in the mobile ECMO team. ELSO team composition includes a cannulating physician and a surgical assistant (to perform cannulation), an ECMO physician, and specialist in addition to a RT.

Our model in Qatar is composed of two ECMO consultants, an ECMO nurse, a perfusionist, a RT, and a Critical Care Paramedic.

Whatever the configuration is, the mobile ECMO team should have the necessary skills and competency to safely initiate, maintain, and trouble-shoot any ECMO or clinical emergency. The team has to be able to manage the critically ill patient on ECMO, medications, ventilator, and invasive monitoring. Due to lack of back up, the mobile team must have all necessary skills for the mission.¹ECMO transport vehicle: It should provide adequate space to accommodate the patient, stretcher, and all attached equipment including ECMO console. Appropriate electric, oxygen, and gas supply, suction, climate control, and lighting are required.^4,5 Ground transport is recommended for distances up to 400 km,¹ generally using a custom-made mobile ECMO unit (Fig. 1).Figure 1.  HMC Mobile ECMO team (with permission). Note the 360° access, space, adequate lighting, and ancillary equipment within the ambulance.

Equipment: The use of checklists is recommended.¹ Mobile ECMO team should be self-sufficient and ensure adequate supply of all ECMO-specific equipment. Limited space during transportation mandates careful selection of transport equipment without exposing the patient or team to risk. The ECMO team must be familiar with equipment and items in sealed pre-packs help expedite the team dispatch.⁴Medications: The same medications used for in-house ECMO are typically used during transport. The team must ensure adequate supply of medication for the duration of the mission and anticipate possible delays. Equipment and medication redundancy, immediate availability of emergency medications, and use of a medication list further enhance patient safety.^1,4Conclusion: Adequately trained personnel, appropriate vehicle, equipment, and medication in addition to meticulous planning are key elements for safe ECMO transport.

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.

This study reports India's first international extracorporeal membrane oxygenation (ECMO) transfer as a joint operation between Hamad Medical Corporation (HMC) (Doha, Qatar), International Critical Care Air Transfer Team (ICATT), and Apollo Hospital (Chennai, India).

Severe respiratory failure (SRF) patients can be transferred safely, and there may be a survival advantage in transferring such patients to regional centers of expertise.¹ Patients can also be transported between facilities while on ECMO.² In the case reported below, ECMO was initiated as a bridge for lung transplant,³ which is currently not a procedure available in Qatar. ECMO support as a bridge for these patients could provide acceptable 1-year survival.⁴ It is also important to note that newer ECMO pumps are small and compact, and can safely be used to transfer patients by air.⁵

The first contact between the HMC and ICATT teams was made a month prior to the transfer of an ECMO patient due for the lung transplant. The patient was a middle-aged male with a very complicated and stormy ICU course, known to have interstitial lung disease (ILD) and ECMO-dependent referred for lung transplant.

The patient issues were:

[1]  Advanced ILD [2]  ECMO-dependent [3]  Resolving septic shock [4]  Frequent sepsis with multiple organisms, bacterial and fungal [5]  Hemothorax [6]  Pneumomediastinum [7]  Deep vein thrombosis [8]  Low body mass index (BMI) of 19 kg/m² [9]  Pulmonary embolism [10]  Bilateral brain microhemorrhages

The challenges were:

[11]  Air logistic [12]  Cost [13]  Long-distance ECMO transfer (Qatar to India) [14]  Complicated patient factor [15]  Poor understanding of ECMO among airport authorities [16]  Pump exchange on arrival

There were initial discussions for the ECMO team from India to aeromedically retrieve the patient from Doha, but considering the cost factor, it was more economically viable for the ECMO team from Doha to perform the transfer and return by the same carrier. An appropriate aircraft was chosen to fit all the equipment and the mobile ECMO team. Preparation of an appropriately staffed and equipped intensive care unit (ICU) ambulance (“Mobile ECMO unit”) along with patient stabilization was performed before the transfer to the airport. A bed in the receiving ICU in India was arranged. A mobile communication application was used from the onset of the transfer to communicate among all the relevant team members, referring hospital, receiving hospital, and the aviation team. It included the intensivists, transplant surgeons, ECMO specialists, perfusionists, logistical lead, and the transplant co-coordinator. The patient was mobilized from the medical ICU in Doha to the mobile ECMO unit, while in India the airport and receiving hospital team re-visited the entire operation from the landing to the airport exit of the ambulance to the hospital. Passport details of the patient and team from Doha were obtained and the immigration officer at Chennai airport, India, was appraised about the criticality and the complexity of the operation. A fully loaded ECMO capable ambulance was mobilized with the full team and stationed at the airport, pre-empting and preparing for a possible pump exchange in the event of any possible complication. Nine hours after leaving the hospital, the team from Doha safely landed with the stable patient. Following multiple negotiations, permission for the tarmac transfer of the patient from the air ambulance to the land ambulance was obtained. The patient arrived safely in at Apollo Hospital, Chennai, India, nearly 6 h after leaving the HMC's MICU.

Background: Transport of patients on ECMO has been demonstrated to be safe, if undertaken by well-trained teams.^1–3 Incorporating an Ambulance Service Critical Care Paramedic (CCP) into the team provides a seamless team dynamic during retrieval improving safety.⁴ The CCP helps to co-ordinate logistics, monitors patient and team safety and provides an additional resource for advanced life support during ECMO patient transport. In addition, they provide a link to decision-making and execution of patient movement systems and help access any additional resources within the Ambulance Service. Seamless team dynamics: The success of each retrieval depends as much on team dynamics as on the technical skills of the individual specialties represented in the team.⁵ In recognition of the central role of the Ambulance Service in ECMO transport, CCPs were included in the working group, training and development process for ECMO at Hamad Medical Corporation in Doha, Qatar. Based on their experience, they led the design of the retrieval service Mobile Intensive Care Vehicle and High-Acuity Patient Transport Trolley, helping to develop a platform and system that provides redundancy and limits the requirement for the ECMO team to carry additional backup equipment. In addition, they are part of activities like developing and participating in ECMO transport multidisciplinary simulations. Patient and team safety: Multitasking is a potential source of medical error.⁴ To allow each member of the team to focus on their specific tasks, the CCP takes a patient and team safety role, oversees the various aspects of the process, and ensures the timing of each process and completion of all tasks before movement. Each step in the patient preparation and movement is confirmed as per the safety checklist to ensure nothing is overlooked, and the risk of accidental snagging of lines, trip hazards and subsequent dislodgment of invasive lines or ET tubes is assessed at each step and thus minimised. Logistics: Successful cannulation by the ECMO team requires them to be self-sufficient and independent of the referral hospital for supplies. Prior to the ECMO team activation, the CCP is responsible to ensure that all equipment boxes, required for cannulation and patient care, are loaded into the transport vehicles, and the subsequent delivery of these boxes to the appropriate venue at the referral hospital. The CCP, being familiar with ambulance service equipment (oxygen, power sources, and electronic equipment placement within the ambulance), is there to ensure appropriate connection, trip hazard and snag risk reduction, and troubleshooting on route. ALS and clinical support: Critical Care or Intensive Care Paramedics have received additional training in Critical Care Transport and Aeromedical Medicine. CCPs within the Ambulance Service are able to provide advanced airway interventions (rapid sequence induction intubation), use multimodal mechanical ventilation and provide advanced cardiovascular life support – including infusion devices, inotropes, external pacing and mechanical chest compression devices. The CCP also plays a support role for the ECMO nurse specialist in preparing the patient for transfer to theatre (infusions, monitoring and ventilation), and becomes lead for the safe movement of the patient from the unit to the theatre, and later to the ambulance.

Extracorporeal membrane oxygenation (ECMO) is a highly complex, resource-intensive intervention. The use of veno-venous ECMO for the management of patients with acute, reversible lung failure has increased significantly over the past 10 years.¹ Advances in ECMO technology have resulted in the development of simpler, safer circuits, which are associated with fewer complications. Concomitantly with the clinical and technological changes in ECMO, the role of the ECMO specialist has evolved to manage patient–circuit interaction and the clinical needs of the patient, and to ensure safety of the ECMO circuit through continuous surveillance, assessment and troubleshooting, as well as preventing and managing circuit emergencies.

The Extracorporeal Life Support Organization (ELSO) defines the specialist as “the technical specialist trained to manage the ECMO system and clinical needs of the patient on ECMO under direction and supervision of an ECMO trained physician”.² Internationally, specialists come from a range of professional backgrounds including perfusion, nursing, physiotherapy and medicine. Each ECMO center, depending on the local needs and the availability of resources, in terms of both manpower and finances, has developed its own local specialist role, training program and staffing arrangements. A recent international survey confirmed that despite variation in funding and practice, the staffing arrangement implemented by most centers responding to the survey was the ECMO specialist nurse providing 24/7 ECMO care supported by perfusionist backup for the technical aspects of circuit management.³ Most centers responding to the survey reported a “two carers” approach to nurse staffing with the ECMO specialist nurse working collaboratively with the bedside nurse to ensure the safe co-ordination and management of a critically ill patient with a wide range of complex needs, including multi-organ system support and complex haematological, fluid and sedation management. In addition to meeting the complex needs of the patient, the ECMO specialist nurse is responsible for ensuring the safe management of the ECMO circuit, which includes the titration of blood flow and sweep gas flow to achieve oxygen and carbon dioxide targets, titrations of blood flows and sweep gas flows to facilitate exercise and the management of emergency situations should they arise. Understanding the management of both patient and circuit and the potential patient–circuit interaction is an essential component of the ECMO specialist nurse role. While other professionals have the educational background and technical skills to function in the role of the ECMO specialist, the advantage of the ECMO specialist with a nursing background is their ability to provide 24-hour care managing all aspects of patients' needs, including administration of medication, and to have the technical skills and knowledge to safely manage the ECMO circuit with perfusion backup for the more complicated aspects of circuit management.

As part of the National Health Strategy in the State of Qatar to improve the healthcare sector, the Critical Care Service in Hamad General Hospital (HGH) sets up an extracorporeal membrane oxygenation (ECMO) service within the Medical Intensive Care Unit (MICU) to enhance the care provided to critically ill patients. The new service demands a new technology and specific staff training in order to maintain high standards and safe care. Therefore, our initial investment was in training the team following ELSO guidelines and the purchase of ECMO equipment, especially for the adult population in our case.

In the State of Qatar, the first use of ECMO treatment as respiratory support was in May 2014. Our experience supports other research that this technique requires expert knowledge and skills to deliver best and safe practice.¹ We believe that this can be developed through regular practice and interaction at the bedside with patients and the ECMO technical equipment. Moreover, planning a robust ECMO education programme for the team is central to improving the quality of care and safety that we provide to these vulnerable patients. As part of our preparation process, in November 2013, six ICU nurses attended the ECMO specialist training course in London (UK). Since then, continuing educational programme has been established to train all the whole MICU nursing team focused on ECMO patient care. Several in-house training workshops and external re-training programmes were provided to nurses to develop their theoretical knowledge and technical skills with other members of the clinical team. In addition, we have performed simulation training that focused on multidisciplinary team, emphasising that teamwork is important and necessary for the care of such patients.

The ECMO specialised nurse who takes care of these patients is educated to provide specialised assessment, appropriate monitoring, and clinical reasoning interventions. In addition to manipulating the ECMO machine, understanding ventilation requirements and the patient's medical treatment is crucial to help the ECMO nurses detect the signs of deterioration early and intervene immediately. Therefore, naturally, the role of the ECMO nurse has expanded and tends to be developed with theoretical and technological developments.² The primary roles being close monitoring of alterations in blood flow and observation and maintenance of the circuit, and also an ability to assess the risks and assist with patient care.

We also compared the role of the ECMO specialist nurse versus the role of the perfusionist. We believe in the importance of both roles; however, we argue that when the ECMO nurse works alongside the ICU bedside nurse, the bedside care becomes more effective. Both nurses and perfusionists are able to understand the patient's overall condition and needs during the ECMO run, and have better interpretation regarding observed changes.³ The partnership promotes the continuity of patient care and allows better communication and support of the family as an aspect of care. This also increases the opportunity of bedside training and education and allows developing other nurses under supervision.

Overall, with proper planning, education, and structuring of ECMO care, we were able to obtain outcomes that are similar to those reported internationally. We aim to further improve patient outcome, especially regarding post-ICU discharge as part of holistic nursing care.

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a highly specialized procedure relying on advanced technology, and specific attention is required to ensure safe operation. Who should or can accomplish this procedure is roughly defined by the ELSO guidelines.¹ Before starting an ECMO program, proper assessment of resource adequacy is crucial, and developing the structure for the program is mandatory. Recommendations can be found on the Extracorporeal Life Support Organization (ELSO) website.² Formal training of the whole team is desired, not to say highly recommended, to be able to provide the best patient care possible.

In the UAE, the need for an ECMO program was identified and formalized in 2009. Two batches of nurses were consequently sent to a high-volume ECMO center in Europe to acquire both theoretical knowledge and practical training in the waterlab to master the required technical skills. Observation of clinical shifts and daily routine for ECMO as well as sharing protocols and policies provided for a safe startup in the UAE. When volume increased and the need for more trained nursing specialists was identified, we developed a three-day specific training course: first day for general introduction, second day for veno-arterial (VA) ECMO, and third day dedicated to veno-venous (VV) ECMO. The course is backed by competency assessment during supervised bedside shifts.

Maintenance of task skills for our ECMO team is achieved during monthly waterlab sessions (de-airing, pump failure, etc.) when not only manual practice is done, but also case presentations and reviews are discussed, team debriefing is done, and lectures are delivered to ensure up-to-date knowledge and understanding. The importance of simulation for ECMO has been described,³ and we made it a focus of our specialist ECMO training. Our concept of training has since then spread over the Middle East area and South Africa.

In 2010, following the H1N1 swine flu pandemic,¹ five severe respiratory centers were commissioned in England. These were established to provide veno-venous ECMO (extracorporeal membrane oxygenation) for patients with refractory respiratory failure. Moreover, it was a condition set out by the commissioning body that each center would carry out a minimum of 20 cases per year to remain certified. The reality of the situation has proved somewhat different. At Guy's and St Thomas’ NHS foundation Trust (GSTT), the annual number of cases has steadily increased. In 2015, the Trust carried out almost 100 veno-venous ECMO cases.² These recent developments in available therapies for patients with refractory respiratory failure or cardiac failure meant that intensive care staff have been exposed to equipment with which they have been hitherto unfamiliar. Clinical perfusion scientists, previously “shackled” to the heart lung machine, have found themselves thrust into clinical, supportive, and educational roles, teaching both nurses and medical staff the ins and outs of the ECMO equipment and being an integral part of the multidisciplinary team retrieving patients from tertiary centers.

This increase in workload has necessitated an increase in staffing requirements across all specialties and an ever evolving training program. All ECMO specialist nurses are required to undergo a comprehensive training program.³ This serves to familiarize them with the equipment used, give them a good understanding of the nuances of the ECMO circuit, and train them to an accepted level of competency in ECMO emergencies. All water laboratory training is carried out by perfusion ECMO trainers. The competencies practiced have evolved to include emergency procedures that staff have encountered over the years since the service began. Since 2009, at Guy's and St Thomas’ NHS Foundation Trust, we have developed a robust and comprehensive training program to ensure that we have a large cohort of well-trained, confident, and competent intensive care staff who are able to handle any ECMO emergencies in a safe and timely manner.

ECMO specialist training involves water drills approximately 3 days a week prior to “signing off” and then mandatory updates every 3 months.³ ECMO consultants and medical fellows also undergo the same training and have yearly updates.

This presentation explains how the role of the clinical perfusionist at GSTT has evolved outside the operating theater environment in training, supportive, and clinical roles.

It also explains the role of the perfusionist in the retrieval process as well as outlining the training program and the three-day bi-annual high-fidelity simulation course developed by the multidisciplinary team in the Trust.

Intensive care unit-acquired weakness is a common sequela of critical illness and is associated with deficits in physical strength, functional performance, and associated health-related quality of life.^1–3 Early rehabilitation in the intensive care unit (ICU) is recognised as safe and feasible.^4,5 Maintaining and restoring musculoskeletal strength and function is recognised as an essential element of therapy in critical care.³

Active rehabilitation of patients with femoral access veno-venous extracorporeal membrane oxygenation (VV ECMO) has been deemed a high-risk procedure and to the authors' knowledge is not a routine practice. There is limited published literature describing the rehabilitation of those requiring VV ECMO in critical care.^6–8 The aim of this study was to explore the active rehabilitation of those requiring VV ECMO.

A retrospective review of the medical records of patients admitted to the Intensive Care Unit at Saint Thomas’ Hospital requiring VV ECMO was undertaken. Owing to the nature of this observational retrospective study, it was exempt from ethical approval. Data were collected for the period from 1 September 2012 to 31 January 2015. Details of rehabilitation sessions were recorded daily on the electronic patient record by physiotherapists. Data on the frequency and type of active rehabilitation, time on VV ECMO, and patient characteristics, including diagnosis, were collected. Active rehabilitation was defined as any of the following interventions: active range of movement, bed mobility, sitting on the edge of the bed, step transfers, mobilisation, and leg cycle ergometer use.

During the study period, 56 patients (30 male) who required VV ECMO were identified. Of them, 55 were cannulated bi-femorally and 1 required femoral and jugular cannulation. The mean (SD) patient age was 44.2 (14.3) years and the diagnoses requiring VV ECMO were: bacterial pneumonia (n = 19), viral pneumonia (n = 20), interstitial lung disease (n = 5), aspiration (n = 2), asthma (n = 4), tuberculosis (n = 2), cancer (n = 1), and non-pulmonary ARDS (n = 3). The mean (SD) duration of VV ECMO was 32 (37.6) days.

Twenty-six patients (46%) participated in active rehabilitation. A total of 808 active rehabilitation sessions were carried out. The active rehabilitation interventions provided were: sitting on the edge of the bed (n = 683); step transfer to chair (n = 112); and cycle ergometer use (n = 13). Rehabilitation sessions generally involved two physiotherapists, one bedside nurse, and one ECMO clinical nurse specialist. Thirty patients (54%) did not participate in active rehabilitation. The reasons recorded for this were either a deterioration in the patient's condition or the indication that the patient did not meet the criteria for active rehabilitation, e.g. Richmond Agitation and Sedation Score <  − 2 or >+2; neurologically inappropriate; or unable to follow commands. No rehabilitation sessions had to be terminated due to adverse events.

This small retrospective cohort study showed that active rehabilitation is feasible in patients receiving VV ECMO, the majority (98%) of whom were cannulated bi-femorally. However, not all patients are suitable for active rehabilitation. Previous local evaluation data have shown that care for those requiring VV ECMO is resource intensive, requiring increased numbers of staff and time compared with those requiring conventional mechanical ventilation. Sufficient resource is essential to ensure a safe, structured, and co-ordinated approach, which enables active rehabilitation for those requiring VV ECMO. Further research is required, investigating the physiological response to exercise in this patient cohort, to inform future practice.

The last couple of decades has brought a lot of changes in thoughts and technology in the domain of simulation-based healthcare education, ranging from emergency preparedness using screen-based technology to the practice of precise surgical procedures with computerised simulators with haptic and performance feedback.¹ There is a perpetually evolving educational and technological simulation continuum available to educators and clinicians promoting the practical and cognitive aspects of healthcare delivery. It is becoming an increasingly competitive market area from an industry perspective as more and more governments invest on technology to support educational initiatives and programmes in order to increase patient safety and standards of care.² Although industry strives to develop more advanced and realistic simulators, it is increasingly argued that it is not necessarily linked to better learning outcomes.³ For an effective use of simulation as an educational approach, a key aspect is to focus on selecting the approach that best addresses the intended learning objectives.⁴

Extracorporeal membrane oxygenation (ECMO) is a bridge therapy that can be separated into several phases from a training perspective such as patient selection, cannulation type (veno-venous (VV)/venous-arterial (VA)/VVA) and process (ultrasound guided cannulation, fluoroscopy cannula placement, securing the cannula, etc.), ECMO patient management and issues, and ECMO circuit issues.⁵ Overall, it is a complex system that all ECMO team members need to grasp at least theoretically in order to be able to support one another at any stage when a problem occurs. The safest way to become familiar with ECMO is to use simulation; however, at present, there is no single simulation platform that allows us to seemingly practise the succession of phases without transiting from one type of simulator to another type, and this is what we are trying to address. At best, and generally only for demonstration purposes (appropriate in that case), we are “simulating the simulation” as a form of deception.⁴ We currently pretend the ultrasound or fluoroscopy procedure by playing a video making observers believe that it is a live view or we ask them to imagine a colour change in the oxygenated blood, which might be a more significant gap.

Several teams have developed their own simulation solution⁶ to bridge a gap in the market or save on the purchase of prohibitive technologically advanced simulators that still have limitations. The simulations for ECMO training often either start post cannulation, whereby a team of learners has to fix a machine or patient issue during the ECMO run, or they concentrate on very technical skills such as cannulation insertion and water drills to practise circuit change. Both aspects are critical but still leave room for missed educational opportunities involving the whole team. Collaboration, generally without commercial ambition, between clinicians, educators, and engineers is now pushing the boundaries of ECMO simulation, making it a more affordable and common practice, but ultimately industrial support is generally required to “mass-produce” and distribute the solutions as we need them: functional, effective, and affordable, so the use of simulation for ECMO training can become a common practice and clinical teams are better prepared to initiate ECMO and deal with emergency situations. We hope to introduce ELSO very soon with a collaboratively developed simulator that meets all key training requirements.

Transfer and retrieval of extracorporeal membrane oxygenation (ECMO) patients is an aspect of a severe respiratory failure (SRF) service, which has generally low volume and high risk thus necessitating attention to particular safety measures. One of the key aspects in preventing patient safety issues and minimising risks of harm during the transportation of an ECMO patient is to develop a well-prepared multiprofessional team. This is the key area where simulation can play a very important role in various stages of a patient care pathway. There is much more to ECMO patient transfer and retrieval than one may suspect as it involves a referral, a lot of planning regarding activation, tasking, transporting, and disposing of the patient at the receiving facility,¹ all of which should be done collaboratively and maintaining open and high communication standards to prevent mishaps.

Simulation is used not only to develop important ECMO-related clinical or teamwork skills, but also to identify potential safety threats.² There are several modalities of simulation that can be used to prepare the clinical team and test processes put in place.³ The modality needs to be selected according to the specific learning objectives expected to be addressed. The full-scale high-fidelity approach is usually the most complex to orchestrate as it would most likely involve the team members, a scenario, a patient simulator or simulated patient (Actor), real clinical equipment, and the patient care setting (ambulance and potentially the referring and/or receiving facility). For this type of simulation to be beneficial to more people than the immediate participants, it requires the scenario to be audio/video recorded with live broadcast into an observation room, where other learners could follow the event and then be engaged in the debriefing with the participants. This does not constitute the ideal starting point of developing an ECMO transport simulation programme but is certainly an objective to achieve to really prepare a team on all aspects of “Mobile ECMO”.

Our recommendation is to start more simply and gradually increase the level of realism and complexity, so that teething issues can be identified and fixed in a more manageable manner. Process testing, new staff orientation, emergency procedures, and understanding of roles and responsibilities are elements that should initially be addressed in a low-fidelity simulation context such as Visually Enhanced Mental Simulation.⁴ It is also important to realise that a scenario, of low or high fidelity, can simply be a snapshot of the Mobile ECMO process, as it helps focus on key pre-identified learning objectives. The starting point might be to simulate how a referral is evaluated via remote patient assessment and how the team is activated. A different phase might involve starting at the point of transferring the newly cannulated patient from the operating table onto the ambulance stretcher and moving through the hospital and loading onto the vehicle (Fig. 1). A whole scenario could take place inside the ambulance during the journey with the ECMO patient. As in real life, the possibilities offered by simulation are endless but need to serve a real educational purpose.