Hospital discharge day for Phoua Yang was more like a pep rally.
On her way rolling out of TriStar Centennial Medical Center in Nashville, Tennessee, she teared up as streamers and confetti rained down on her. Nurses chanted her name as they wheeled her out of the hospital for the first time since she arrived in February with covid-19, barely able to breathe.
The 38-year-old mother is living proof of the power of ECMO 鈥 a method of oxygenating a patient鈥檚 blood outside the body, then pumping it back in. Her story helps explain why a shortage of trained staff members who can run the machines that perform this聽聽has become such a pinch point as covid hospitalizations surge.
鈥淥ne hundred forty-six days is a long time,鈥 Yang said of the time she spent on the ECMO machine. 鈥淚t鈥檚 been like a forever journey with me.鈥
For nearly five months, Yang had blood pumping out a hole in her neck and running through the rolling ECMO cart by her bed.
ECMO is the highest level of life support 鈥 beyond a ventilator, which pumps oxygen via a tube through the windpipe, down into the lungs. The ECMO process, in contrast, basically functions as a heart and lungs outside the body.
The process, more often used before the pandemic for organ transplant candidates, is not a treatment. But it buys time for the lungs of covid patients to heal. Often they鈥檝e been on a ventilator for a while. Even when it鈥檚 working well, a ventilator can have its own side effects after prolonged use 鈥 including nerve damage or damage to the lung itself through excessive air pressure.
Doctors often describe ECMO as a way to let the lungs 鈥渞est鈥 鈥 especially useful when even ventilation isn鈥檛 fully oxygenating a patient鈥檚 blood.
Many more people could benefit from ECMO than are receiving it, which has made for a messy triaging of treatment that could escalate in the coming weeks as the delta variant surges across the South and in rural communities with low vaccination rates.
The ECMO logjam primarily stems from just how many people it takes to care for each patient. A one-on-one nurse is required, 24 hours a day. The聽聽that many hospitals in hot zones are facing compound the problem.
Yang said she sometimes had four or five clinical staff members helping her when she needed to take a daily walk through the hospital halls to keep her muscles working. ECMO is unusual as life support, because patients can be conscious and mobile, unlike patients on ventilators who often are sedated. This presents its own challenges, however. For Yang, one person鈥檚 job was just to make sure no hoses kinked as she moved, since the machine was literally keeping her alive.
Of all the patients treated in an intensive care unit, those on ECMO require the most attention, said nurse Kristin Nguyen, who works in the ICU at Vanderbilt University Medical Center.
鈥淚t鈥檚 very labor-intensive,鈥 she said one morning, after a one-on-one shift with an ECMO patient who had already been in the ICU three weeks.
The Extracorporeal Life Support Organization said the average ECMO patient with covid spends two weeks on the machine, though many physicians say their patients average a month or more.
鈥淭hese patients take so long to recover, and they鈥檙e eating up our hospital beds because they come in and they stay,鈥 Nguyen said. 鈥淎nd that鈥檚 where we鈥檙e getting in such a bind.鈥
Barriers to using ECMO are not merely that there aren鈥檛 enough machines to go around or the high cost 鈥 estimated at $5,000 a day or significantly more, depending on the hospital.
鈥淭here are plenty of ECMO machines 鈥 it鈥檚 people who know how to run it,鈥 said Dr. Robert Bartlett, a retired surgeon at the University of Michigan who helped聽.
Every children鈥檚 hospital has ECMO, where it鈥檚 regularly used on newborns who are having trouble with their lungs. But Bartlett said that, before the pandemic, there was no point in training teams elsewhere to use ECMO when they might use the technology only a few times a year.
It鈥檚 a fairly high-risk intervention with little room for error. And it requires a round-the-clock team.
鈥淲e really don鈥檛 think it should be that every little hospital has ECMO,鈥 Bartlett said.
Bartlett said his research team is working to make it so ECMO can be offered outside an ICU 鈥 and possibly even send patients home with a wearable device. But that鈥檚 years away.
Only the largest medical centers offer ECMO currently, and that has meant most hospitals in the South have been left waiting to transfer patients to a major medical center during the recent pandemic surge. But there鈥檚 no formal way to make those transfers happen. And the larger hospitals have their own covid patients eligible for ECMO who would be willing to try it.
鈥淲e have to make tough choices. That鈥檚 really what it comes down to 鈥 how sick are you, and what鈥檚 the availability?鈥 said Dr. Harshit Rao, chief clinical officer overseeing ICU doctors with physician services firm Envision. He works with ICUs in Dallas and Houston.
There is no formal process for prioritizing patients, though a national nonprofit has聽. And there鈥檚 limited data on which factors make some covid patients more likely to benefit from ECMO than others.
ECMO has been used in the United States throughout the pandemic. But there wasn鈥檛 as much of a shortage early on when the people dying of covid tended to be older. ECMO is rarely used for anyone elderly or with health conditions that would keep them from seeing much benefit.
Even before the pandemic, there was聽intense debate聽about whether ECMO was just an expensive 鈥渂ridge to nowhere鈥 for most patients. Currently, the聽聽for covid patients on ECMO is roughly 50% 鈥 a figure that has been dropping as more families of sicker patients have been pushing for life support.
But the calculation is different for the younger people who make up this summer鈥檚 wave of largely unvaccinated covid patients in ICUs. So there鈥檚 more demand for ECMO.
鈥淚 think it鈥檚 100% directed at the fact that they鈥檙e younger patients,鈥 said Dr. Mani Daneshmand, who leads the transplant and ECMO programs at Emory University Hospital.
Even as big as Emory is, the Atlanta hospital is turning down multiple requests a day to transfer covid patients who need ECMO, Daneshmand said. And calls are coming in from all over the Southeast.
鈥淲hen you have a 30-year-old or 40-year-old or someone who has just become a parent, you鈥檙e going to call. We鈥檝e gotten calls for 18-year-olds,鈥 he said. 鈥淭here are a lot of people who are very young who are needing a lot of support, and a lot of them are dying.鈥
Even for younger people, who tend to have better chances on ECMO, many are debilitated afterward.
Laura Lyons was a comedian with a day job in New York City before the pandemic. Though just 31 when she came down with covid, she聽. ECMO, she said, saved her life. But she may never be the same.
鈥淚 was running around New York City a year and a half ago, and now I鈥檓 in a wheelchair,鈥 she said. 鈥淢y doctors have told me I鈥檒l be on oxygen forever, and I鈥檓 just choosing not to accept that. I just don鈥檛 see my life attached to a cord.鈥
Lyons now lives at her parents鈥 house in central Massachusetts and spends most days doing physical therapy. Her struggle to regain her strength continues, but she鈥檚 alive.
Since it鈥檚 kind of the wild West to even get someone an ECMO bed, some families have聽, as their loved one waits on a ventilator.
As soon as Toby Plumlee鈥檚 wife was put on a ventilator in August, he started pressing her doctors about ECMO. She was in a northern Georgia community hospital, and the family searched for help at bigger hospitals 鈥 looking 500 miles in every direction.
鈥淏ut the more you research, the more you read, the more you talk to the hospital, the more you start to see what a shortage it really is,鈥 he said. 鈥淵ou get to the point, the only thing you can do is pray for your loved one 鈥 that they鈥檙e going to survive.鈥
Plumlee said his wife made it to sixth in line at a hospital 200 miles away 鈥 TriStar Centennial Medical Center, where Phoua Yang was finishing her 146-day ECMO marathon.
Yang left with a miracle. Plumlee and their children were left in mourning. His wife died before ever getting ECMO 鈥 a few days after turning 40.
This story was produced as part of NPR鈥檚 partnership with Kaiser Health News and Nashville Public Radio.