Extracorporeal Life Support The ELSO

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 Table of Contents
Dedication ............. 1$ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 8 •••• V
th
Preface to the 5 Edition ............................................................................................... xvii

I. Extracorporeal Life Support: General Principles

1. The ffistory and of Extracorporea] Support..•.....•••..............••••....•.•..1

Support: Earliest Beginnings ......................................................... 1
.,nr",," of ECMO ~~~~ .. ~ .... ~~ .... ~~ .... ~ .....,. . ~ ......."."....... ~ ........... *._.".. * ••• ~"~ .. ** •• ~~ .... 6 ¥ . . . . . ,, . . . . . . . * ••

Perseverance: and Growing Indications in Adult ECMO ................... 9

2. The

A Conversation with Dr. Jay Zwischen berger....................................................... 22

3. Evolution and ffistory Global ELSO .................................................................. 25

................................................................................................ 26
ELSO .......................................................................................... 27
South and West Asian ELSO .............................................................................. 28
References ............................................................................................................ 29
4. The Physiology of Extracorporeal Life Support .....................................................31
Cardiopulmonary Physiology ............................................................................... 31
Cardiopulmonary Pathophysiology ......................................................................33
Cardiopulmonary Pathophysiology during ECMO
The ECMO Circuit. ............................................................................................. 34
Modes and .............................................................36

5. The Circuit........................................................................................ t> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '" 49

49

lastl.cmlrs ..................................................................................... 51
ECLS Circuit Components ...................................................................................52
Table ofContents

Commercial Centrifugal Pumps .......................................................................... 60

Gas Exchange Devices .........................................................................................63
Commercial Gas Exchange Devices ..................................................................... 65
Gas Exchanger Related Complications ........................................................ ,...... 70
Heat Exchange and Heat Regulation ........................................................ ............ 71
Heat Exchanger Related Complications ............................................................... 72
Circuit Priming .....................................................................................................73
Circuit Monitoring ....... ......................................................................................... 73
Summary ................................................................ ........................ ....................... 75
References .................... .............. ............................ ...............................................76
6. Adverse Effects ofECLS: The Blood Biomaterial Interaction ................•.............81
Introduction ........................... ............................................... ................................. 81
Nonnal Hemostasis ........... ............................................................. .. ................... 82
Activation of the Coagulation Pathway ................ ............................. ................... 82
Activation of the Fibrinolytic Pathway ................................................................. 83
Developmental Hemostasis .................. .. ............. .. ................................................ 83
Coagulation Pathway Activation and Inflammatory Response ........................... 84
Activation of the Coagulation System during ECLS ........ .................................... 87
Activation of the Innate Immune System .............................................................. 87
Endothelial Function in Hemostasis and Circuit Modifications .................... ...... 88
References ........................................... .. ............................................................... 90
7. Anticoagulation and Disorders of Hemostasis........................................................ 93
Introduction ....................................... .................................................................... 93
Anticoagulation .. ................................................................ ................................... 93
Anticoagulation Monitoring ..................................................... .. .. .........................95
Anticoagulation Laboratory Schedule and Blood Product Replacement... .......... 98
Hemorrhagic and Thrombotic Complications ..................................................... 99
Conclusions ................................. ......................................................................... 99
References .......................................................................................................... 100
8. Transfusion Management during Extracorporeal Support ................................ 105
Blood Product Transfusion during Extracorporeal Support ............................... 105
Use of Coagulation Factor Replacement ............................................................ III
References ........................................... ........... .. .. ................................................. 117

ll. Extracorporeal Life Support: Neonatal Respiratory Disease

9. Neonatal Respiratory Diseases .............................................................................. 123

Introduction......................................................................................................... 123
Congenital Diaphragmatic Hernia (CDH) ............. ... .......................................... 123
Meconium Aspiration Syndrome (MAS) ............................................................ 123
Persistent Pulmonary Hypertension of the Newborn .......................................... 126
Pneumonia/Sepsis ................ .......................... ................................ ..................... 127
Surfactant Deficiency - Hyaline Membrane Disease ........................................ 128
Surfactant Deficiency - Tenn Infants in Respiratory Failure ........... ........... ...... 129
References ..................... ..................................................................................... 130

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 Table o/Contents

10. Congenital Diaphragmatic Hernia ECMO .................................................. 133

133
Diagnosis ........................................................................................................... .
134
Mechanical Ventilation ..................................................................................... .
Inhaled Oxide ........................................................................................... 1
Sildenafil ............................................................................................................. 135
lmervelluons .............................................................................................. 136
Management Adjuncts ........................................................................................ 137
ECMO ................................................................................................................. 137
Summary ............................................................................................................ .

Neonates with Respiratory Failure ........ 151

151
u","",,,,,,,.. Selection Criteria ,..~~~**~ ...,.*~~ .... ~,. ......... *~ ~~~~.~.~~* .......... 6~
.... ... ~.~~~ "~~"'.e .... ~ ..... ~*~ 151
* ............... .. ,. .. B ..

1
Contraindications
Weight kg ...................................................................................................... 154
Gestational Age wks ................................................................................... 154
iemorrtlage ..................................................................................... 155

Chromosome Abnormalities ............................................................................... 156

Pre-ECMO
157
12. ECLS Cannulation for Neonates with Respiratory Failure ............................... 159
.................................................................................................................. 159
vv- or VA­ ........................................................................................... 160
Choice of Cannula and Vessel ........................................................................... 160
Cannulation Technique ....................................................................................... 161
Post Cannulation liJ.,u"i'>H15
167
13. Congenital Comorbidities among Respiratory Neonatal ECLS Patients •......•. 169
Background ........................................................................................................ 169
Congenital Anomalies ........................................................................................ 169
Malignancies ...................................................................................................... .
llU'",", . .Ull" ............................................................................................................ 173

.......................................................................................................... 175
Errors of Metabolism .............................................................................. 176
Abnormalities ........................................................................................ 176

Conclusion .......................................................................................................... 177

178
14. Medical Management ofthe Neonate with Respiratory on 183
and ...................................................................... 183
Respiratory......................................................................................................... 184

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Table ofContents

Cardiovascular .................................................................................................... 186

Infection .............................................................................................................. 187
ECMO Circuit Considerations in the Neonatal Patient .................................... .
Hematologic ....................................................................................................... 190
Neurologic 191
Summary ............................................................................................................ 194
195
15.

Cardiovascular .................................................................................................. .
Neurologica1. ...................................................................................................... 204
Fluid JJu,Jt.....""v.L'-VJUu,u

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 Table ojContents

ExtracorporeaJ Support: Pediatric Respiratory Disease

18. Pediatric Respiratory Diseases Predisposing to £.t'L,JU;:h........'. .........'...................." .. .!,.:1 ...

for KeSPlratC)ry "'1T~TV,rt

Failure
Asthmaticus
The Inununocompromised ..................................................................................233
MediastmallH'L;);)<O;)
uillionary Hemorrhage .................................................................................. ..
Perioperative Support for .......................................................
Air ................................................................................................ 234
Preoperative Rehabilitation ............

<;:t''l1~t,...1''V Support of Patients Congenital Heart L'L:'"'''"'''''

Prolonged Respiratory ECLS ..............................................................................235

References ........................................................................................................... 23 7
Contraindications in Children with Respiratory Failure .......... 239

239
:ontramlOlC'ltIODS ................................................................................................ 242
244
244

20. ECLS Cannulation for Children with Respiratory Failure ................................247

Preferred Routes
Technique ........................................................................................................... 248
Complications .....................................................................................................252
254
21. Comorbidities ."ULIULU"i!:; Pediatric Patients with Respiratory Failure .................. 255

Hospital n.HULU.\V . . .

Prediction of Mortality Risk Prior to Initiation........................................ 261

Conclusion ..........................................................................................................262
References ...........................................................................................................263
22. Management ofthe Pediatric Respiratory Patient on ECMO ..............267
Introduction.........................................................................................................267
...."1'1'''nT Mima.gclnelnt .......................................................................................... 268

276
lLA..d.V1.\J .........................................................................................

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Diagnostic Tools in ECMO ................................................................................. 277

Other Interventions ............................................................................................ 278
Complications .................................................................................................... 278
Followup ............................................................................................................ 278
Conclusion ...................................................................................................... ... 278
References .......................................................................................................... 279
23. Nursing Management ofthe Child with Respiratory Failure on ECLS .......•... 283
Introduction ......................................................................................................... 283
Daily Assessment ................................................................................................ 283
Daily Patient Care .............................................................................................. 284
Wound Care ......................................................................................................... 286
Daily Activities .................................................................................................. .287
Conclusion ................................................................................................ ......... 288
References...................... .................................................................................... 289
24. Weaning and Decannulation of Children with Respiratory Failure on ECLS..291
Strategies for Withdrawal of ECLS Support....................................................... 291
Withdrawal ofECLS Support as Palliative Withdrawal of Care ........................292
Weaning Support and Trialing ............................................................................ .292
Technique for Decannulation of Patients on Venovenous ECLS ........................ 293
Continuing Venous Access after Decannu1ation ................................................ 294
Approaches to Inadvertent Decannulation ............. ............................................ 294
References ........................................................................................................... 296
25. Outcomes, Complications, & Followup of Children with Respiratory Failure 297
Introduction .................................................................... ..................................... 297
Outcomes ............................................................................................................ 297
Long-term Outcomes ........................................................................... .............. 299
ECMO Complications ........................................................................................ 300
References ............................................................................... .. ......................... 304

IV. Extracorporeal Life Support: Neonatal and Pediatric Cardiac Disease

26. Neonatal and Pediatric Cardiovascular Diseases Predisposing to ECLS ..........307

Introduction .........................................................................................................307
Indications and Outcomes .................................................................................. 308
ECMO in Patients with Functionally Univentricu1ar Circulation ..................... .312
Outcome and Risk Factors for Death ..................................................................313
Conclusions........................................................................................................ 314
References ...........................................................................................................315
27. Extracorporeal Cardiopulmonary Resuscitation in ChHdren ..•.........................321
Introduction ......................................................................................................... 321
ECPR Definition ................................................................................................. 321
ECMO for Failed CPR ........................................................................................ 321
ECPR Utilization and Epidemiology ................................................................. .322
Survival to Hospital Discharge after ECPR ............ ........................................... .322
Patient Selection for ECPR .................................................................................323

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 Table ofContents

MfmagerneIlt Strategies ..................................................................................... .

ECMO in Previous ",n"""'''"''''''
ECMO for ACHD

Stabilization ................................................................................. .
1-'ft>",r"'1"",fn'l>

Support ........................................................................................ 340

I-'Pf·llU,pr,.1"n,p

Mechanical Support beyond Perioperative

Low Output Syndrome ......................................................................... 340
to Transplantation.................................................................................... 341
ULl~.I-.n~'LI"" Support . .AU'LI

Cardiac ,"-"WlHILU<U,lVLl

347
,"-"WlLU"ll(n,lVLl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Transthoracic Cannulation ................................................................................. 348

Venting ............................................................................................................... 350
Not Venting 1
Troubleshooting .................................................................................................. 351
Conclusion ......................................................................................................... 354
References...........................................................................................................355
Comorbidities and in Pediatric Patients for Cardiac •••••...•.357
Background ......................................................................................................... 357
Preexisting
Acquired ...................................................................................... 361

References.......................................................................................................... 364
Medical Management of Neonates & Children with Cardiovascular Disease •.367
Introduction.........................................................................................................367
Utilization ECLS

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Table a/Contents

Management of Common Issues for Cardiac Patient ....................... 368

Cardiovascular Assessment and Monitoring ..................................................... 370
Ventilator M~magelneJ[lt

Other Organ System to the Cardiac ECLS Patient ...... 372

",u,"',v"",,,,a, Support

Conclusion ......................................................................................................... 374

33. Nursing Management of Children with Cardiovascular Disease ..................... 379
Introduction ........................................................................................................ 379

Prevention of Infection ...................................................................................... 380

Neurologic Considerations ................................................................................. 381
Rehabilitation ......................................................................................................382
Integumentary Considerations ............................................................................3 82
Nursing in Rapid
Family -':H'''\nrl,rt

34. Weaning Pediatric Cardiac ECMO.......................................................................387

Introduction.........................................................................................................387
When to Attempt Weaning .................................................................................. 387
Predictors of Successful Weaning ...................................................................... 389
Weaning Trial ................................................................................................... ..
Speed of Weaning .............................................................................................. 390
for ........................................................................... 390
Decannulation .................................................................................................... 390
Failure to
Conclusion ..........................................................................................................393
394
35. Outcomes/Complications/Followup of with Cardiovascular Disease 395

Longt;:r-tl~rm Survival
Early Neurological Outcome
LOJl1ge:r-u~rm Neurodevelopmental Outcome ...................................................... 397
Long-term Quality ofLife (QOL)
FoUowup ............................................................................................................ 398

References........................................................................................................... 401

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 Table ofContents

Extracorporeal Support: Adult Respiratory Disease

36. Adult Respiratory Diseases Predisposing to ECLS............................................. 405

M,magernelltApproaches to Respiratory ........ ..405

Syndrome (ARDS) ............................ .406

hCltlocardllOlloca()llV in Acute ,-nn"\"v,Pfn'

Immunosuppressed ...................................................................................407
ofARDS ............................................................................................. 409
Lung Biopsy ............................................................................................. 4
411

37. Indications & Contraindications in Adults with Respiratory Failure .............. 415
15

424
38. ECLS Cannulation for Adults with Respiratory Failure ...................................

LTJ.~U~~'''' for Adult Respiratory

Aspects
,"""UUL'..,al for Adult Respiratory Failure
References...........................................................................................................436
39. Comorbidities among Patients with ......,....",'1........, Failure ....................... 439

Comorbidities
Comorbidities lOemUlOO
Impact of Comorbidities on Outcome
Specific Common Comorbidities and Their with ECLS ................. .442
Summary............................................................................................................ 444

1.I'",.n.,_i-.... 1r"1L1 Failure on ECLS ........... 449

Prone I:'matlClnIrlg
Bronchoscopy .................................................................................................... 450
Airway 450
Tracheostomy 1
Awake 1
Cardiovascular Vasopressors and 1

xxvii
Table a/Contents

Right Heart Failure ............................................................................................. 452

Venoarterial SuppOtt......................................................'" ...................................452
Arrhythmias......................................................................................................... 452
Sedation Management. ........................................................................................452
Delirium .............................................................................................................. 453
Intracerebral Hemorrhage ........................... .. ...................................................... 453
Renal Support .................................................................................................... 454
Nutrition ............................................................................................................. 454
Endocrine Support ............................................................................................. 454
Hematological Abnormalities ............................................................................ 454
Infection as the Indication for Respiratory ECLS Support ................................ 454
Infection Complicating ECLS Support ............................................................... 455
Conclusion .......................................................................................................... 456
References........................................................................................................... 457
41. Nursing Care of the Adult Respiratory ECLS Patient..•...............................•.... 459
Introduction ........................................................................................................ 459
ECLS Specific Nursing Care ............................................................................. 459
Checklists and Preventative Care ...................................................................... 459
Cannula Care ..................................................................................................... 460
ECLS Circuit Observations and Monitoring of Circuit Function ...................... 460
Console Settings, Safety, and Responses ........................................................... 460
Renal Replacement ............................................................................................ 460
Emergency Responses ........................................................................................ 461
General Nursing Care of the ECLS Patient ....................................................... 461
Neurological Assessment and Sedation Practice (and Awake ECLS) ............... .461
Patient Moves and Pressure Area Care .............................................................. .461
Prevention of Bleeding ............................................ ........................................... 462
Hygiene and Infection Prevention ..................................................................... .462
Nutrition .............................................................................................................. 462
Bowel Management ............................................................................................ 463
Staff Support ....................................................................................................... 463
Role Allocation ................................................................................................... 463
References .......................................................................................................... 464
42. Weaning and Decannulation ofAdults with Respiratory Failure on ECLS..... 465
Introduction .........................................................................................................465
VV-ECLS Physiology ......................................................................................... 465
Initiation ofVV-ECLS ........................................................................................466
Maintaining VV-ECLS ....................................................................................... 466
Recirculation .......................................................................................................467
Weaning VV-ECLS ............................................................................................ 468
Liberation and Decannulation ............................................................................ 468
Other Modes of Support ................................................................. ................... 469
The Patient Who Cannot be Weaned .................................................................. 469
Conclusion ......................................................................................................... 469
References.......................................................................................................... 470

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 Table ofContents

43. Outcomes and Complications ofAdult Respiratory ECLS...••...•............•.•.••......471

Short-term Outcome ofARDS Patients on VV-ECLS ...................................... .471
Long-term Outcomes after ECLS for Severe ARDS ......................................... .4 72
Main ECLS Related Complications and Their Impact on Outcome.................. .472
Mortality Risk Factors and Outcome Prediction for ECLS Candidates ............ 474
Volume-Outcome Effect and ECLS Activity Organization ................................ 474
Conclusion .................................................................................................... ......475
References ...........................................................................................................476

VI. Extracorporeal Life Support: Adult Cardiac Disease

44. Adult Cardiovascular Defects, Diseases, and Procedures .................................. 479

Acute Myocardial Infarction ...................................... ........................................ 479
Postcardiotomy ................... ................................................................................ 481
Acute Myocarditis .............................................................................................. 484
Acute Pulmonary Embolism ................ .............................................................. .486
Cardiogenic Shock in Other (Rare) Non Surgery-Related Etiologies ............... 488
Cardiocirculatory Support or Bailout Assistance ............................................. 488
Preoperative Support ......................................................................................... 489
Acutely Decompensated Chronic Cardiomyopathy .......................................... 490
Conclusions......................................................................................................... 491
References........................................................................................................... 493
45. Extracorporeal Cardiopulmonary Resuscitation in Adults .•..•...•....•....•..•.•.•..•.••501
Introduction ......................................................................................................... 501
Definition ofECPR............................................................................................. 502
Organizational Issues Related to ECPR Implementation ........... .. ......................502
Facilities and Equipment Appropriate for ECPR................................................ 503
The Ideal ECPR Patient ...................................................................................... 503
ECPR Cannulation Technique ........................................................................... 504
Optimal Cannula Diameter .................................................................................506
Reperfusion Technique and Initial ECLS Flow Setting......................................506
Complications during Implantation and Initial Launching .................................506
Rhythm Analysis, Conversion ofVentricIe Fibrillation ...................................... 507
Postresuscitation Care Monitoring ..................................................................... 508
Studies on ECPR in mCA................................................................................. 508
Studies on ECPR in OHCA ................................................... ............................ 509
Studies on ECPR in the Pediatric Population .................................................... 510
ECPR as a Stepwise Approach to Refractory CA.............................................. 510
Weaning from ECLS after ECPR....................................................................... 510
Ethical Issues in ECPR ...................................................................................... 510
Future .................................................................................................................. 511
References...........................................................................................................512

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Table ofContents

46. General Considerations for VA-ECMO Implantation••........•............•.................517

Peripheral VA-ECMO is Fast and Easy to Implant ............................................ 517
Peripheral VA-ECMO is Efficient as a Circulatory Support Device .................. 517
ECMO is Cost Effective ..................................................................................... 517
ECMO Does Not Unload the Left Ventricle ...................................................... 518
ECMO Decreases the Transpulmonary Flow .................................................... 518
ECMO is Associated with a High Rate of Complications ................................. 518
ECMO Requires the Patient to Stay in Bed ....................................................... 518
ECMO and Hemodynamic Criteria ................................................................... 519
ECMO and Neurological Status ........................................................................ 519
ECMO and Cardiac Arrest ................................................................................. 519
ECMO vs. Other Short-Term Circulatory Support Devices .............................. 520
VA-ECMO and Contraindications ..................................................................... 520
Conclusion ......................................................................................................... 520
References ........................................................................................................... 521
47. Cannulation for ECMO in Adult Patients with Cardiac Failure ...................... 523
Peripheral Cannulation ......................................................................................525
References.......................................................................................................... 530
48. Adult Cardiac ECLS Acute Complication and Comorbidity Management..•.. 533
Introduction ......................................................................................................... 533
Acute Complications during ECLS ..................................................................... 533
MuItimorbidity Patients .................................................................................... 539
Summary ............................................................................................................ 540
References........................................................................................................... 542
49. Medical Management of the Adult with Cardiovascular Disease...............•.•.....551
Introduction ......................................................................................................... 551
General ICU Management ................................................................................. 551
Monitoring of the ECMO Circuit .......................................................................552
Daily Echocardiography Monitoring .................................................................. 552
Management ofPuImonary Edema under VA-ECMO ....................................... 553
Blood and Coagulation Issues ............................................................................. 553
Cannula Site Related Complications ................................................................. 554
Nosocomial Infections .............................................. ......................................... 554
Drug Pharmacokinetics ...................................................................................... 554
Weaning from VA-ECMO ................................................................................... 555
Conclusion ..........................................................................................................555
References ........................................................................................................... 556
50. Nursing Management of Adults with Cardiovascular Disease ...........................561
Introduction ......................................................................................................... 561
Management ofthe ECMO Device .................................................................... 561
Preventing Complications .................................................................................. .562
Adopting the Specifics of ECLS to Patient Regular Monitoring ........................565
References ...................................................... ................................. ................... 568

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 Table oJContents

51. The Weaning Process and Decannulation in Adult Cardiac Patients ............... 569
569
Echocardiography in the Weaning t'rocess ... . 570
Decannulation .................................................................................................... .
VA-BCMO Decannulation
I..irnpropn'!" BCMO JJVV<WJLU ...................................................................... 572
Conclusion ..........................................................................................................572
References ...........................................................................................................573
Neurologic and Pulmonary Complications Adult ECLS ............................... 575

Factors Determining Neurologic Outcome.........................................................575

Incidence ofNeurologic
Factors and Complications .......................................... 577
to Work and Quality of Life ............................................. 579
Conclusion ........................................................................................................... 580
1

VB. Extracorporeal Support: Special Indications

53. Pregnancy and Extracorporeal Life Support ......................................................

Physiological Changes Pregnancy ..........................................................583
Adult Respiratory Distress Syndrome Pregnancy
Severe Cardiac Disease in Pregnancy ................................................................. 585
Considerations for ECMO during ..........................585
Complications ................................................................................... 588
Specific to during BCMO ................... .
Experience with BCMO in Puerperium
References ........................................................................................................... 591
54. Trauma and Extracorporeal Life Support .......................................................... 593
Introduction.........................................................................................................593
Indications for in Trauma Patients .......................................................... 594

55. Transport oftbe Patient Supported with ECMO ............................................... 599

Inter-Hospital Transport ..................................................................................... 599
u ...,,~.....,.. Transport ............................................................................... 607
Conclusion ......................................................................................................... 608
609

Indications .......................................................................................................... 614

Contraindications ................................................................................................615
Cannulation ........................................................................................ 615
Central ........................................................................................... 618
Management on ECMO ..................................................................................... 619
Table

57. Extracorporeal Life for Severe Cardiotoxic Drug Poisoning .............." ...
Introduction.........................................................................................................627
ECLS for Poisoning-induced Cardiovascular Failure .......................................627
Venovenous Poisoning-induced Respiratory
Conclusion
634
58. ECMO as Bridge to Lung Transplantation ......................................................... 639
Introduction ........................................................................................................ 639
..................................................................................... 639
ECMO

in the Intraoperative and Posttransplantation "''''.U1'''''':>

Outcomes ofECMO as ............................................................................. 644
Limitations to ................................................................... 644
644

EeLS in Heart Transplantation ........................................................................... 649

649
Pretransplant 649
ECLS after Transplantation.......................................................................655
References.......................................................................................................... 659
60. Immunodeficiency and ECLS ............................................................................... 665
Introduction .........................................................................................................665
Support in Pediatric and Adult Patients Solid Organ Blood Cancer ....665
ECLS in Patients
mOlca1[}OJJIS, Contraindications and
ECLS in with Hematopoietic Stem Cell Transplant (HSCT) ...667
Technical Considerations ...................................................................................667
ofECLS to Manage Respiratory Failure after HSCT ..................................667
Use of ECLS to Manage Heart Failure ......................................... 668
Vascular Access .................................................................................................. 668
Mana!l~ement of Coagulation after HSCT ............... "............................... ".......... 669
Human Immunodeficiency Virus (HIV) Patients .................... ..
in Patients PJP: the South Africa ................................. 669
ECLS Candidate Selection for H1V+IPJP+ ...................................................... 670
Drugs (ARVs) and ECLS ............................................................ 670
ECLS in Adult and Pediatric Autoimmune 670
 Table

ECLS: Procedures and Adjunctive Extracorporeal Therapies

61. Procedures on
679
Questions ................................................................ 680
General Principals .............................................................................................. 680
General Measures ............................................................................................... 681
ECMO Related Procedw
Ul~l!mostlc Procedures
Procedures General ...............................................................................683
and Burn P"t;""t"
Specific Surgical Procedures in Respiratory ECMO .......................................... 687
Specific Surgical Procedures in Cardiac .................................................. 687
Conclusion ........................................................................................................ .
62. Extracorporean EUmmation ..........'..............................,................,....'...............·............. \j'7
Acute Kidney (AKJ)
Apheresis during 701
References.......................................................................................................... 708
63. Extracorporeal Carbon Dioxide Removal ........................................................... 713

Considerations ECC02R ..............................................................................713

5
.......................................................................................... 715
........................................................................................ 716
Impact of Low Extracorporeal Blood Flow ........ 716
Management Considerations the Event of Circuit Failure
Weaning .............................................................................................. 717

718

Intraaortic J.JU.UV~'H
IMPELLA ...........................................................................................................723
Levitronix ........................................................................................ 724
Anticoagulation ...................................................................................................725
Right Ventricular

xxxm
Table ofContents

IX. Extracorporeal Life Support: Organization

65. 1mplementing an ECLS Program ..........................................................................731

Identify the ECMO Service ....... ........... ............................................... .., ........... . 731
IdentifY Your Customer ................................ ............... ........... .. ......................... ..732
Identify the Employees and Equipment Needed ..... ........... ........ .................. .. ....733
Develop the Key Processes ....... .. ............... ........ ............... ...................... .. ......... 734
Mistake-Proof the Processes ............................ .. ...................... ........................... 73 5
Develop Measures, Improvement Goals and Controls .......................................735
Continuously Improving and Sustaining a Program .. .. .. .................................... .736
References ..................... ...... .......................... ......... ..................... .. ..................... 738
66. Centralization and Regionalization of ECLS Resources..................................... 741
Background ...... ............. ......................................... .......... ..... ...................... .. ...... 741
Relationship of Centralization to ECMO.................................................. .......... 741
The ECMO Center ................. .. .......... .. ............................................................... 742
Outlying Centers and Critical Care Transport .................................................... 743
ECMO Transport... ............. ............................... ........ .. ........... .......... ............. .... .. 743
Summary ........... .............. ... ........... ..... .. .. ... .. ........... .. ..... ........ ........... .............. .. ...745
References ..... ................ .......................... .. ...... ..... .. ........... .... ............ .................. 746
67. Education and 'frainilllg ..........................................................................................747
Introduction .. .......... .. ............... ........... ..... .. ...... ............. .. .... ... ..... .. ................... .. .. 747
Educational Process .......... .. .......................... .. ............ ....................................... 748
Establishing ECMO Competency .... .......... .. .......... ............ .... .............. ............ .. 749
ECMO Training Program .... ................ ... .. ..... .. ............... .. ................ ........ .. .. .... .. 750
ECMO Training Course Curriculum .............. ...... ............................................. 750
Didactic (Classroom) Course .... ...... .................. .................................... ... ......... .. 751
Training Labs .............. ......... ........................ ................ .. .... ... ... .............. ............ 754
Water Drills .. ......... .. ........... .... ......... ............. .. ... ..... ............................................. 755
Animal Lab .............. ................... .......... ......................... ....... ............. ..................755
High Fidelity Simulation .. ......... ........................ .............. .... ......... ... .......... .. ....... 755
ELSO ECMO Training Course .......... .................... .............................................756
Maintaining Competency Standards .............. .. ................ ........... ............... ......... 757
Maintaining ECMO Competency ............. ...... .. .. .......... .. ................................... 758
Summary .. ....... .. .... ... ............ ...... .. ................. .......... ....... ........... ................. .. ...... 759
References ........... ..... ........ ............ .. ......... .............. ..... ... ... ....... ...................... ..... 760
Addendum 67-1 .......... ... .............. ................... ........ ............. ......... .................. ..... 762
68. Quality of Care in ExtracorporeaJ Life Support. ................................................ 765
Introduction ... .......... ....... ..................................................................................... 7 65
Summarizing the Evidence for Interventions to Improve Outcomes .... .. ...........766
Identify Local Barriers to Implementation of Changes .................................... .. 767
Performance Measurement ........... .. ......... ..... .. ......... ................. ..... .................. ... 767
Implementation of the Interventions ........ .. .......... .. ... ......................................... 768
Data Collection and Measuring Quality ............................................................ 768
Quality in Small vs. Large ECLS Programs ........ ............ ............ .. .......... .. ........ 769
New Technology ..... ............ .. ....... ... ... ..................... .. .. .. .. .. ....... ................. .. ..... .. 769

xxxiv
 lable

769
770
69. The Economics of ECMO...................................................................................... 773

International Models of ECMO

The ofECMO ......................................................................................... 778
References.......................................................................................................... 779
70.

hXlpan,<1111IgUtilizations ofECLS: Application and Resource Allocation ........... 781

Complex Medical Decision in ECLS: Starting and Stopping ECLS ....783
p<lP"rl'h in Ethical and Controversy
U ...""h".,1 Considerations .................................................................................... 788

Conclusion ......................................................................................................... 788

71. Strategies for Medication Management in ECLS ............................................ ...

Pharmacokinetics ................................................................................................795
Pharmacokinetic Changes Critical Illness ECLS ..................................... 797
Experience and Recommendations Based on Medication Class ....................... 798
General Strategy
References ...........................................................................................................806
72. The of the Extracorporeal Life Support Organization ....................... 809
Data Collection ................................................................................... 810
Registry ................................................................................................. 811
Current Data Summary 12
Neonatal Trends ..................................................................................................812
Pediatric Trends .................................................................................................. 812
Adult Trends ........................................................................................................812
Cardiac Trends
Summary
814
Glossary 815
9 ..................................................................................................................................

Appendix 1: Pediatric ECLS Cannula Characteristics ..............................................817

Appendix Adult ECLS Cannula Characteristics (Edwards) ................................ 818
Appendix Adult Cannula (Medtronic).............................. 819
Aplpendix 4: Adult Cannula (Maque11:) .................................. 820
APlpendix 5: Adult ECLS Cannula Characteristics (Sorin) .......................................821
Appendix 6: Adult ECLS Cannula Characteristics (Medos) .................................... 822
Appendix 7: Double Lumen ECLS Cannula Characteristics .................................. 823
Index .................................... 825
0 ..........................................................................................................................

xxxv
1

The History and Development of Extracorporeal Support

James D. Fortenberry, MD, MCCM, Roberto Lorusso, MD, PhD

"During that long night, helplessly watching blood driven by a syringe to the right heart
the patient struggle for life as her blood became to generate circulation in an animal
darker ... the idea naturally occurred to me that model. Results promising, but limited by
ifit were possible to remove continuously some lack of UU"'V"'UF.'L"U~'VJU, leading Richardson to
ofthe blue blood... put oxygen into that blood. .. ':t"'I'<ltll'n [and artificial

and then to inject continuously the now-red v,.,,,,,,,.v,,,, process, and that it
blood back into the patient s arteries, we might el~ments oftime, experiment
have saved her life". development of a demon­

-.John Gibbon MD
UIV'UVlli

-
science."2 In the 1920's
. Brukhonenko and

Extracorporeal Support: Earliest Beginnings

Surgeon John Gibbon eloquently described

above the anguish and powerlessness he felt as
a young research fellow in 1931 over the loss
of a young patient to a pulmonary embolism.!
The memory of that single patient was the
impetus for Dr. Gibbon to embark on an effort
dedicated to the proposition that mimicking or
replacing normal human body cardiopulmonary
functions during an acute illness could save
lives. However, the remarkable story of the
development of extracorporeal support can be
traced as far back as 1693, when Jean Baptiste
Denis performed expenments cross-transfusing
the blood of a human with the "gentle humors
ofa lamb" to determine ifliving blood could be
transmitted between two species (Figure 1-1).
Benjamin Ward Richardson MD, noted British Figure 1-1. Woodc~ing of experiments circa
1693 by Jean Baptiste Denis to drain human
physician and anesthetist, conducted experi­ blood into a sheep.
ments in the 1860s using injected oxygen and

1
Chapter 1

collaborators developed a total body perfusion

system, called the "autojector," using excised chronicles of early
donor animal lungs for blood oxygenation, and IAnrrop,nt were captured by
later a bubble oxygenator, to perfonn successful edition of the ELSO
animal experiments with isolation ofthe heart. 3 "Red Book. "4,5
Dr. Gibbon began his journey to further While use ofextI1acorr'on~a support proved
advance the field of extracorporeal support in gs in the operating
humans in the 1930s. Collaborating with his "."~,,,._~ use past several hours
wife Mary at Jefferson Medical School in Phila­ problematic. Early
delphia, Dr. Gibbon developed a freestanding for extracorporeal sup­
roller pump device for extracorporeal support. the nature of available
The initial Gibbon heart-lung machine was the and blood gas interfaces,
size of a spinet piano that created thin films blood component dam­
of deoxygenated blood passing over a screen age from the direct "''''.'".".... to oxygen gas. 6,7
exposed to oxygen. 1,4 Twenty-two years would Bubble oxygenators not create an interface
pass before Dr. Gibbon was able to use the de­ between blood and producing hemolysis
vice in the operating theater. On May 6, 1953 he within hours.
perfonned the first successful extracorporeally The next steps' the development of ex-
assisted repair of an atrial septal defect in 18 tracorporeal were a testimony to the
year-old Cecilia Bavolek (Figure 1-2). collaboration biomedical engineers,
The esteemed cardiac surgeon C. Walton physiologists, and surgeons to cre­
Lillehei, MD (Figure 1-3) further advanced ate devices that provide support for more
extracorporeal circulation in the operating room extended time inside and outside the OR
in 1954 when he performed cardiac surgery via lysis and plasma leakage.
cross circulation and then progressed to using drove this breakthrough:

Figure 1-2. John H. Gibbon MD and patient Cecilia Bavolek, who the landmark repair in
1953 of an atrial septal defect utilizing an extracorporeal circuit. The two before the Plexiglas-
covered "lung" ten years after the procedure. Right: original device, Upt"V"1.Uf"""" J the size ofa spinet
piano (source: Jefferson University Archives).

2
 The History and )ev'elo'plf/ent ofExtracorporeai Support

the invention of silicone and the ability to al­ less heparin would
low prolonged circuit-blood exposure through showed circuits could be
controlled anticoagulation.8 The development of clot formation or hem or­
synthesis of silicone rubber by Kammermeyer Drinker also described
in 1957. revolutionized the artificial lung. 8,9 approach to continuously
Silicone possessed the strength to withstand "'V':l~U"aLJVp and heparin dosing via the
hydrostatic pressure and yet remain permeable a time honored approach
to gas transfer, Collaborative innovators, in­ place for over 40 years.?
cluding Drs, Theodor Kolobow, Al Gazzaniga, extracorporeal support
Phil Drinker, and Robert Bartlett pioneered and recovery postopera­
experiments in developing a silicone membrane congenital heart disease
lung that allowed prolonged circulation l . Kolff nh'VC;:1/~j""c;: to expand its operating
and Kolobow independently identified and ad­ al. 13 first reported the use
vanced the use of silicone membranes for gas for surgery itself,
exchange, and Kolobow identified the enhanced from other centers. In
gas exchange activity of a spiral-wrapped and
silicone membrane. 9,lo The use of the silicone
"membrane oxygenator" also led to the use of
the term extracorporeal membrane oxygenation tilrr\{'pn,"'pfor correction of
(EeMO). Bypass became feasible in animal great vessels; they subse­
models for days at a time. II arr\nl1rnrt series ofcases. 14 In­

Bartlett and Drinker also recognized that pa~lents related to low cardiac
the cardiac patient in the operating room needed failure or pulmonary
"infinite" anticoagulation due to stagnation in lowing surgical repair of
open surgical repair, but with long-term cir­

Figure 1-3. Bubble oxygenator invented and first use in 1954. Left: Richard DeWall with
device. Right: Dr, C. Walton Lillehei, cardiovascular surgeon and innovator cardiopulmonary bypass.

3
Chapter J

With this improved technology, extracor­ bedside from the "... ",,."t-n"', and sought consent
poreal support was extended outside of the from the infant's who had delivered her
operating theater. Dr. J.D. Hill reported on the
first successful cannulation and prolonged extra­
corporeal circuit use in a patient in an intensiye
care setting in 1972. 15 The patient was a 24-year
old male with a ruptured aorta and posttraumatic
acute respiratory distress syndrome following
a motorcycle accident, and who was supported
with a membrane lung developed by Morrie _5).19,20 Bartlett's success
Bramson. The patient received venoarterial helped drive growing
support for 75 hours, with subsequent decan­ of use in neonates around
nulation and survival. Adult ECMO support ivors among 16 patients
efforts continued, although survival rates were coworkers, clinical
initially low. outcomes improved,21.23 which
Meanwhile, the use of ECLS in newborns
and neonates also expanded. Dorsons and White
reported experience with trials ofextracorporeal
support l6, 17 in moribund patient cases at the end
of life, demonstrating the capability of the sup­
port system to provide adequate oxygenation.
Surgeon Dr. Robert Bartlett (Figure 1-4),
who has been called the father of modern extra­
corporeal support, made a therapeutic decision
in 1975 that brought this burgeoning technology
to neonates with primary respiratory conditions.
Faced with a newborn infant dying from meco­
nium aspiration pneumonia and resultant pul­
monary hypertension, Bartlett and colleagues
brought an ECMO oxygenator to the NICU

Figure 1-5. the first infant

successfully EeMO for primary
respiratory : Esperanza and
Figure 1-4. Dr. Robert H. Bartlett. The Father daughter with Dr. K"rrlPTTat ELSO conference.
ofECMO.

4
 The
promoted the interest and application in the
surgical and intensive care community. Pub­
lished reports showed ongoing improvements
in outcomes, increasing survival rates 75% for
neonatal diseases previously associated with
only 10% survival.
Expansion ofthe use ofECMO in neonates
ran counter to typical use of new medical and
technologic interventions, which had typically
advanced first in adults. With growing interest,
the medical community sought randomized,
controlled trial (RCT) evidence ofthe benefits
of neonatal extracorporeal support over stan­
dard therapies. Dr. Bartlett and colleagues at the
University ofMichigan initiated an ECMO RCT
with an intriguing statistical twist to give pref­
erence in the trial to a therapy which appeared
superior. Their "randomized play the winner"
approach began with randomization but gave
increased preference based on the success or
failure ofthe previous patient. During the study,
the first patient receiving ECMO, survived. The
next patient, randomized to standard care, died.
Increased preference went to ECMO, and the
next ten patients, all receiving ECMO, survived
(p=.OOOOOOI). The study24 was published in
l.2.8..5 to sjgnificant controversy and discussjon,
including concern that control patients did not
undergo informed consent. The findings, how­
ever, encouraged growing use ofECMO support
Figure 1-6. Dr. Pearl O'Rourke, principal
investigator of early neonatal ECMO random­
ized trial.
H~tmy and Devetopl nt ofExtracorporeai Support
in neonates. Cente performing ECMO grew
from only 18 wor dwide to over 100 centers
in the early 1990 . Thanks to technological
advances, neonatal and pediatric application of
ECMO became a c romon practice.
A second pros ective trial effort took ad­
vantage ofECMO d traditional, non-ECMO
therapy being pro ided in separate intensive
care units. Dr. Pear O'Rourke, a pediatric criti­
cal care physician a Boston Children's Hospital
(Figure 1-6), led a 0 phase RCT. The study
design included a phase one approach with
a traditional 50/50 randomization of patients
until one arm had four deaths, followed by a
phase two utilizing Ian adaptive design to favor
the ''winner'' of th9 first phase. Overall, 19/20
(97%) ofECMO pa ients survived compared to
60% of standard c ntrol patients. 25 The study,
published in 1989, engendered controversy in
the medical cOriiin . and in the media.26,27
Ironically, an outc arose from many medical
professionals and e la ress that randomiza­
tion to standard th ra without ECMO was
a loss of equipoise and
recognition that ECMO
had become a stan d of ~re.
The long-desir d RCT evidence for out­
come benefit in ne~atal ECMO for persistent
pulmonary hypert sion was provided by a
study performed in he United Kingdom from
1993 to 1995 28 that emains to date the lar est
randomized ECMO trial. The study, authored
by Drs. David Fiel ,Richard Firmin, and col­
leagues, enrolled 55 penters and took advantage
of the country's re~' o nalized medical! ECMO
system, with rando ization either to stay in the
referral center for s . ndard therapy or transfer
to the regional EC 0 center. A significant
survival difference (pO% in ECMO patients vs.
40% with standard tperapy; number needed to
treat: 3-4) supported the superiority ofECMO
in neonatal respirat Iry failure, and etched the
value ofECMO in s one.
5
Chapter I
Global Spread ofECMO
Even absent the elusive "perfect" trial, sup­
port for, and use of ECMO in neonates grew
globally. Neonatal ECMO served as a role
model for rapid propagation of medical tech­
nology for treatment of disease, and served as
a demonstration model in a National Institutes
ofHealth workshop for diffusion of technology
in 1990 (Figure 1-7), outlining the meteoric rise
from concept to clinically accepted, if still con­
troversial, therapy. The NIH workshop Chair,
Dr. Anne Lennarson-Greer, noted, "The diffu­
sion of an innovation is a highly social process.
The spread of even a simple technology... is
characterized by many interpersonal contacts
and differentiated social roles."29
The concept of rapid technology diffusion
as a social enterprise aptly described ECMO
well before the days ofsocial media. Dissemina­
tion of information for ECMO accelerated with
the initiation of meetings and networks dedi­
cated to ECMO issues. Multiple centers sprang
up nationally and internationally, often with
movement of physicians and staff to develop a
new center, and always with collaboration from
the experienced centers. For instance, in 1983,
only three institutions regularly performing
ECMO (Medical College ofVrrgiuia, University
-~ IUC!
Clinical Re search
UM Mull lcenter
I
Randomized Trials
UM Seminars /
I
/
/ / RegISl'Y
// Standard
-:;7
Treatment
1975 ·60 '82 '84 '86
Figure 1-7. Graphic representation of devel­
opment and propagation of ECMO, from NIH
Report ofthe Workshop on Diffusion ofECMO
Technology, 1993.
6
ofMichigan, and U versity ofPittsburgh) were
represented at one I f the meetings. By 1986,
nineteen institutions rovided ECMO support to
neonates. 3D A volun ry alliance of these active
centers emerged. In 989, a steering committee
formed (Table 1-1 a d Figure 1-8) and created
the bylaws to form the Extracorporeal Life
Support Organizati ,n (ELSO). The purpose
of ELSO was to po~common data on ECMO
use, compare outcoes, and exchange ideas for
optimal use ofECM I support. ELSO meetings
attracted representati es from the small number
of institutions performing ECMO to present
their experience. The rowing interest in ECMO
led to the deVelOpmelt of a week-long meeting
totally dedicated to E MO directed by Dr. Billie
Short and sponsored y DC Children's National
Medical Center. Att~dance was broadened by
a growing internati nal community experi­
ence. The communi . of international ECMO
experience also gre~ with the first European
symposium on extra10rporeal lung support in
Paris in 1991. This m]ting was associated with
the foundation of the uropean Extracorporeal
Life Support Organiza ion (EESO). In 1994, the
international ECMO + nference represented the
first combined meet~g ofELSO and EESO.
ELSO became the epicenter for the develop­
l
ment of thought and ~efinition of the operation
ofan ECMO center a guidelines which could
l
Table 1-1. Charter Members of First Extra­
corporeal Life Supp rt Organization Steering
Committee, 1989
Members
Robert Bartlett
William Kanto
Location
Ann Arbor, MI
Augusta, GA
Fred Ryckman , Cincinnati, OH
Larry Cook Louisville, K Y
Martin Keszler Washington, DC
~ Billie Lou Short Washington, DC
·90
P, Pearl O' Rourke Seattl e, WA
'86
1. DeVil Cornish San Diego, CA
Charles Stolar New York, NY
Michael Klein Detroit, MI
Phyllis McClellan Ann Arbor, MI
Sandy Snedecor Ann Arbor, M
 The History and ofE'xtracorporeal Support

EXT RACORPOItEAL LIFl-~ SUPPORT ORGAN

Cliartf!r Meeting
Or.loJ..er 1-:3, 198 9 Ann Arbur, M.irMglln

Figure 1-8. Top: Attendees at Charter Meeting of the 1·<v1h-,or·nM~nr,,><.

Organization, October 1989. Bottom: Attendees at 25th
ELSO, September 2014.

7
Chapter J
be utilized by a growing number of centers. In
addition, it became the steering organization
for future randomized trial work. Awards for
ELSO Centers of Excellence were developed
to provide center recognition around ELSO
recommendations. The Award of Excellence
has received recognition by entities such as the
annual US News and World Report survey as a
marker of institutional quality.
Key efforts of ELSO included the publica­
tion of manuals and textbooks to help codify
approaches to ECLS care. The need for a col­
lated text ofECMO knowledge was recognized.
Two members of the steering committee, Drs.
Robert Arensman and Devn Cornish, edited the
inaugural edition of this textbook, now known
as the "Red Book," in 1992. The Red Book
has now entered its 5th edition in 2016 as a
collaboration of experts in the global ECMO
community.
A critical element ofpropagation ofECMO
technology was the development of a standard­
ized international patient database to track
results and provide evaluation of indications
and outcomes in a large population, a huge
improvement over traditional small case series
experience. This early database, which trans i­
tioned into the ELSO Registry,31 allowed for
participating institutions to collate and compare
I!?
G>
C 250
G>
0 200
..
'0
350
300
G>
.c
E
:>
z
150
100
n
III-
50
0
Figure 1-9. Growth of ELSO Centers 1989-2016 (ELSO Registry centers
annually to 2015). Over 467 centers were ELSO members worldwide in 201
8
outcomes with the national and international
centers. Internationrl ELSO Registry involve­
ment grew from 80 Eenters in 1990 to over 467
active centers in 201 and well over350 ce ers
contributing da~ igure 1-9). From Registry
inception to date in 017, the Registry database
has captured over 8 ,000 atients and provided
data for hundreds 0 ublications and countless
queries for centers eeking experience around
ECMO use in a spe ific condition. The Regis­
try is the largest re ository of extracorporeal
support data in the orld and is considered the
gold standard for r porting U.S. and interna­
tional ECLS outcomes. Use ofneonatal ECMO
peaked in 1992 at aroullif 1500 annual cases.
The deveI ofl ~dditionaI new therapies
such as inhaled nitri ~ oxide likely contributed
to a decline in the n mbers of neonates requir­
ing ECMO, to curren levels half of those at the
peak of neonatal use
Efforts to use EC MO for pediatric cardiac
and respiratory failw e rose with the success of
neonatal ECMO and ts availability in growing
numbers of centers. A variety of case series
supported the effica( y of ECMO in pediatric
respiratory failure. 32, ~ However, the relatively
low numbers of pedi~tric patients suitable for
ECMO across the couptry precluded a definitive
A
trial. multicenter iT was attempted in the
I':
:I
000 &
000 '0
!
..
fo~~
fOoo
i
Z
000
 The History and Developm nt ofExtracorporeal Support

1990s by Fackler and Heulitt, but was stopped dard therapy utili) g a computerized protocol
due to enrollment difficulties, and lower than for ventilator man gement. The study again
expected mortality in the study population. 34 showed no differen in outcomes. Study design
In the absence of a pediatric RCT the most sig­ concerns included e lack of experience with
nificant case-control study35 demonstrated im­ extracorporeal use in some centers as well as
proved outcomes associated with use ofECMO. extremely high bi od loss in ECMO patients.
To date, no new pediatric RCTs are on the Despite these disa ointing study results, phy­
horizon. Efforts in pediatrics became focused sicians such as Dr. uciano Gattinoni 42 and Dr.
on delineating optimal timing and indications Bartlett persevered~ ' its use in adults, reporting
for support, 36 pushing the envelope for pediatric significant surviva improvement compared to
indications,37,38 and determining relationships historical controls.
between center volumes and outcome. 39 Advances in E MO experience, equipment,
and expertise pave the way for another RCT in
Perseverance: Experience and Growing adult respiratory £~lure, i?e 2009 United King­
Indications in Adult ECMO dom CESAR tri~, under the leadership ofDr.
Giles Peek.43 The ESAR trial took advantage
Since the initial efforts ofDr. Gibbon, clini­ of the regionalized ECMO system which had
cians sought to utilize the benefits of ECMO to allowed the success of the neonatal UK trial,
allow recovery in adult cardiac and respiratory with patients rand~mized to either remain at
failure. However, the road to acceptance of a standard treatmept center or be transferred
ECMO's benefit in adults was a slow one. The to a regional EC~O center. The study also
first attempt at an ECMO RCT was actually an utilized venovenou. (VV) cannulation, with its
NIH-supported adult trial directed by Zapol inherent advantage . Patients receiving care at
et al. comparing venoarterial (VA) ECMO to the ECMO center Idemonstrated significantly
standard therapy for severe respiratory fail­ improved intact sutival compared to standard
ure. 40 The study, while well intentioned, was center treatment. T re study results, while con­
hampered by a variety of factors, including the troversial due to some method . . ita­
choice of moribund patients for study entry, hons, served to sup ort the growing interest in
participation of the majority of centers with no adiilttherapeutic p tential.
previous ECMO experience, and the utilization The timing ofr lease ofthe CESAR results
ofVA cannulation patients potentially requiring shortly preceded e 2009 worldwide HINI
only respiratory support. The trial utilized the influenza pandemi~. The ;acute, severe, fulmi­
relatively poor-performing technology available nant nature of res iratory failure with HINI
at the time, and lung protective strategies were led providers to se k ECMO as a therapeutic
not utilized in either ann. The study demon­ option, with encolaging findings supporting
strated very poor survival (approximately 10%) potential ECMO b nefit. 44,45 The convergence
in both study arms. These findings, although helped supercharg international growth of
clearly underlining the complexity of the clini­ ECMO use. Both E~SO Registry reports31 ,46 and
cal scenario (66% mortality in total population studies ofindepend,nt national data registries47
and 90% in severe ARDS patients), put a chill demonstrated a mar~ed rise in adult cannulation
on subsequent extension of ECLS in adult re­ in ~ubsequent year , with a continued upward
spiratory failure. trajectory to presen .
A later adult RCT in 199441 randomized This rise in us I of ex1racorporeal support
patients with ARDS to receive either extracor­ was fuelled by se~eral major advancements
poreal CO2 removal with VA support or stan­ in equipment, inc uding improvements in

9
Chapter 1

oxygenator components, ECLS circuit and removal opened th door for potential sup­
configuration, and vascular access. Femoro­ port for a large num I er of adults with chronic
femoral cannulation with reduced cannula sizes, obstructive pulrnona disease'S ECMO teams
I

prevention of limb ischemia through selective also pushed the env lope in expanding indica­
distal perfusion, active drainage of limb ve­ tions for extracorp~real support previously
nous flow, and attention paid to left ventricular considered contrain.~ications, wit~ reports of
unloading all played a critical role in enhanced
improved outcomes :~auma, malignancy, and
ECLS management, reduced complication sepsis on ECMO. 56,57 e use ofECLS for acute
rates, and improved outcome. Vascular access extracorporeal suppo during cardiopUlmonary
techniques transitioned from surgical cutdown resuscitation (ECPR)~ISO became a burgeoning,
and insertion towards emphasis on peripheral if somewhat controve sial indication for support,
access employing Seldinger technique, with with growing use in b th children and adults. 58-60
thin, small size, percutaneous cannulas, often
Global growth ~ECMO use has charac­
characterized by nonthrombogenic surfaces. terized recent decad s. ECLS use in Europe
Cannula design (double lumen cannula for VV­ has been both longs ding and innovative. In
ECM0 48.49 or low profile cannula fQr arterial particular, the enhan~ed use in adult respira­
access) and the routine application of a distal tory and cardiac fail r~ has been prop~gat~d
limb perfusion in case of femoral artery can­ in great part by exp nence and expertise m
nulation for peripheral venoarterial approach European centers. IntfmationaJ center growth
were additional breakthroughs for successful also resulted in the establishment of ELSO
ECMO application with significant reduction global chapters tied t o every continent. Eu-
in postprocedural complications. These in­
novations increased use of VV cannula60n, Table 1-2. Chronol~~ v of Steering Committee
with transition to predominance ofVV use for Chairs-ELSa and Gl bal ELsa Chapters.
pediatric respiratory failure in 2012.31 Years Chair
Coating and heparin-bonded circuit sur- ELSO
2016-2018 Michael McMullan
faces,5o together with the miniaturization and
2014-2016 James Fortenbeny
integration of pump systems, led to the develop­ 2012-2014 William Lynch
ment of more simplified, portable, and efficient 2010-2012 Steve Conrad
ECLS systems. The most significant recent step 2007-2010 Mike Hines
2004-2007 Heidi Dalton
was the development ofthe polymethyl pentene 2002-2004 Joseph Zwischenberger
membrane oxygenator, which allowed achiev- 2000-2002 Ronald Hirschl
ing a low priming volumes, oxygenator pressure 1997-2000 Charles Stolar
1994-1997 Michael Klein
drop, high oxygenation efficiency, and long­
1993-1994 Bill ie Lou Short
lasting membrane performance. 5l Preferential 1989-1993 Robert Bartlett
use ofcentrifugal pumps for pediatric and adult Euro ELSO
support also grew. 2014-2017 Roberto Lorusso
2012-2014 Giles Peek
Several trends in management also altered Asia Pacific ELSO
ECMO care. In Europe, efforts to allow pa­ 2013-2017 Graeme Maclaren
tients to remain awake and enhance mobility Latin American ELSO
2015-2017 I Luiz Caneo
were popularized, particularly by the ECMO
2013-2015 Rodrigo DiazJJavier Kattan
team at the Karolinska Institute,s2 allowing for I (Co-chairs)
longer runs, bridging for transplant, and the South aDd West Asia ELSO
2018 Venkat Goyal
capacity for ambulatory ECMO. 53 ,54 Primary 2017 Malaika Mendonca
use ofECMO for extracorporeai carbon dioxide 2014 -2016 Suneel Poobani

10
 The History and Developm ent ofl:7xtracorporeal Support

roELSO was chartered in 2011 as a sequel to Table 1-3. Fello~ ship of the Extracorporeal
the previous European Extracorporeal Support Life Support Org2,nization: Members of Inau­
gural Classes.
Organization (Table 1-2). Asia Pacific ELSO
soon followed, being chartered in 2013, and Inau2ural Class Members 2015
Latin American ELSO and the South and West Robert Bart ~tt MD
Asia ELSO chapters soon followed also in 2013, Konrad FaThe MD
all with the support ofthen-ELSO chair Steve Luciano Ga inoni NID
Conrad. These vibrant organizations allowed John Gibbo MD
accelerated growth of international ECMO Robert E. G oss MD
patient capture in the Registry, robust scientific J. Donald H II MD
conferences, expanded training courses, and Theodor (n d) Kolobow MD
Pearl O'Rou ke MD
enhanced global networking among ECMO
Billie Short VID
providers and centers. Individual membership
John Toom~ ian CCP
in ELSO was also initiated in 2016 to draw in C ass ofW16
members from around the world, whether or not Warwick Butt MD
their institution was an ELSO center. Robin Chap nan RN
The next chapter in the development of J. Devn Con ish MD
extracorporeal support remains to be written, Jean-Yves Chevalier MD
but it was the authors of the preceding works Richard Firmin MD
who set the stage. 10 2015, ELSO established Masahiro N~~ayo MD
Fellowship in the Extracorporeal Support Orga­ Giles Peek ~
nization, an honorary designation to recognize Antonio Pes nti MD
Peter Rycus fvn>H
these pioneering contributors to the ECMO
Charles Stol ~ MD
story (Table 1-3). Much more work remains to
Warren Zap< I MD
be done to improve ECMO technology, predict Joseph (Jay) ~wischenberger MD
outcomes, and fine tune best indications. 47 ,61 As
we seek to fulfill Dr. Gibbons' quest for lifesav­
ing support, we should be encouraged by the
inspiring words of Sir Winston Churchill, "The
future is unknowable, but the past should give

-
us hop~'62

11
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 Repeat the same procedure the next day. Vary the introduction
somewhat, like this: “I want you to do this just as you did yesterday,
except that I want this margin over here on the right side to be on a
straight line. Wait till I take this ruler and show you.” Lay the ruler
lengthwise of the sheet you want the pupil to write on, so that you
can take your lead pencil and make a line about an inch from the
right side of the page. “Now, when you have written out to this line
here, then stop and begin on the next line like this:” (show the child
how you write a sentence and begin on the next line). It would be
well if the sentence which you use as an example were to be one that
would express some familiar thought about the child’s immediate
interests, such as his favorite sport. Leave the child’s desk as you
were advised to leave it the day before and also return as before and
approve that which the pupil does well, either saying absolutely
nothing about the careless parts or suggest incidently that the pupil
could help such and such a part by doing this or that thing to it. Be
sure to end your remarks by some such expression as, “That’s good,”
or “That’s fine.”
(3) Learning to Draw. Not infrequently it Lower Grades
happens that a pupil comes into school who
has never learned to draw and who, feeling his inability to
accomplish the task set for him in the drawing lesson, refuses to
make any attempt to do so. Especially is this true if the picture is to
be drawn from imagination. In such a case it is best to begin with
copying. When this art is learned, drawing from imagination will be a
comparatively easy step.
For example, choose a very simple picture for the child to
reproduce on another piece of paper. It is a good plan for a teacher to
have at least a dozen or more pictures in one drawer of his desk all
the time, because many pupils like to draw and copy pictures and it
is an excellent way to get them interested in other work. Present the
picture of some ordinary scene. Tell the pupil before he begins that
you are going to make a collection of pictures which your pupils
draw. The picture need not have much life in it to start with, but right
here we make use of the child’s imagination to wonderful advantage.
Suppose the picture, which you have in hand, shows a tree or two, a
house, a couple of bushes or any kind of natural objects whatsoever.
Talk to the pupil in this fashion, pointing to different parts of the
picture with your pencil and have your face near the picture,
indicating interest and enthusiasm as you talk: “Now, right behind
this tree here, I want you to draw a boy, sticking his head out from
behind the tree. And right over here, where I make this little cross
mark, I want you to draw a little girl hiding behind this bush. We will
suppose they are playing ‘Hide and Seek.’ Right over here, between
this tree and the house, draw a boy’s hat. Maybe he has lost it while
he was running to hide. You know how to make a hat. Just like this:”
(draw a very simple hat, merely making a straight line and a semi-
circle connecting two points in it.) “Maybe you can draw a better one
than that. I’ll come back to your desk pretty soon and see what kind
of a hat you drew and also that little boy sticking his head out from
behind the tree. Is your pencil sharp enough?”
The child will say that his pencil is all right. Then leave him at once
and in ten or fifteen minutes return. Go back with this one thought in
mind, that you will say nothing at all except that which is
complimentary. For example, say, “Well, I should say you can draw. I
believe you made a better hat than I did. Now this afternoon, I am
going to give you something else to draw. Maybe a pony with a boy
on his back and a girl riding in the pony cart. You are going to be
good at drawing things for me, I know. I want to keep all of your
drawings after you have finished them for me.”
In case the child should interrupt and ask to draw the pony right
away instead of waiting until afternoon, answer by saying, “I will
have the picture ready for you after dinner and then I will bring it to
you.”
Of course, it is not necessary to use the exact words we have
suggested, or to use the same pictures or even to use pictures at all.
The important point is to offer something that is at once interesting
in order to get the pupil started in drawing. Do not insist much upon
regular lessons during the first day or two in which your chief
problem is to get the pupil’s confidence.
After the child has learned to like to do the things which you
suggest present more difficult, or even purely imaginative, subjects
for drawing.
Use the same method in getting the child to take an interest in
other subjects than drawing—that is, give him very small tasks, then
approve and compliment him on his ability. This will bring good
results with any pupil who is normal.
As a transition step between mere copying and drawing wholly
from the imagination, and also to give the timid child confidence
enough to come to the blackboard to draw in the presence of other
children, the following might be tried.
Having the confidence of the little pupil, go to his desk just before
school closes in the evening and say, “I would like for you to stay just
a moment after school. I want to tell you something.”
After most of the pupils have marched out, return to his desk,
begin to talk enthusiastically about a picture which you have. Tell
him to follow you and you will try to draw it. Then after reaching the
blackboard and picking up a piece of crayon, say, “Now, I am going
to draw this man’s face and I want you to draw his eyes.” Let it take
you about a minute to draw the outline of the man’s face, talking all
the time about how well you like to draw pictures, then say, “Now
let’s see if you can draw his eyes. Make a mark right there” (point to a
spot). “Good! Now draw his other eye. Good! Now his ear. Make a
mark right here” (point to a spot). “My, that’s fine. See, what a fine
man you drew.” Start to leave the blackboard and say, “I’m going to
have you draw for me again.”
Repeat this process every day until you feel sure that the child will
go to the blackboard and work in the presence of yourself and the
class.
 DIVISION VII

Only through the gateway of personal experience does the child enter into the
larger understanding of the thought and achievement of humanity.
 CASES ARISING OUT OF THE SOCIAL
INSTINCTS

1. The Unsocial Child

Every teacher knows of a first grade child that came moping when
all the other pupils were in high glee, that stood by himself when
others were enjoying a game, that preferred to come to school alone
and to saunter home alone, that took no part in any of the activities
that always interest other youngsters, that even seemed indifferent to
the friendly approaches of playmates and teacher. There may be no
particular harm in having such a child in school, but should he carry
such traits into adult life, they would prove a serious handicap; so it
is important that the teacher should attempt to help him to throw off
his peculiarities. This can be accomplished very easily. In attempting
a cure she should not make the child feel that she thinks him
different from other pupils.
The best place to begin helping the child is on the playground. Talk
to him about the interesting features of the games. Though he may
not at first show interest, the teacher should keep this up for several
days, until he has learned to know the teacher as a friend. Then she
can invite him to join in the games. It is only an abnormal child that
will not enter into the sport after repeated invitations.
After the child has taken an active part in the games, the teacher
may begin to pay special attention to him in the school-room. To
cause the child to eliminate his peculiarities is entirely a matter of
arousing his devotion to those things which interest other children.
The teacher should appeal to his interests until she has won his
complete confidence. Then she should introduce him to a new
activity. Little by little she will displace the child’s peculiarities with
abiding concern in all those things that interest the other children.
The individual who reaches mature life still possessed of
characteristics that make him an exceptional person is likely to lead a
more or less isolated life unless his peculiarities are such as to make
him acceptable as a leader. Under ordinary conditions, “society tends
to penalize those who do not conform to its customs, its standards,
its attitudes.” This is true even of the unsocial, or non-social
individual; still more does it hold in respect to the anti-social
member of the group.
2. Anti-Social Tendencies—Selfishness, Jealousy, Cliques and
Snobbishness
(1) Selfishness. Selfishness is a trait of character that has always
elicited severe criticism from society. Its manifestations are so
conspicuous that they provoke men to despise and avoid the
confirmed egoist. It is an anti-social trait, hence deserving of the
opprobrium placed upon it, yet it is the basis of all the social virtues,
hence the place which is here given to it in the division on “Social
Instincts.”
We may well believe that selfishness was a universal trait of the
race in its infancy. By this is meant that every individual instinctively
seeks to care for his own interests above those of anyone else. All
during the earlier months, and perhaps years, of one’s childhood, he
measures the world in terms of its service to his own comfort and
pleasure. As one who merges into later childhood and into adult life,
he normally narrows the play of this trait of character, and inhibits
those impulses which, if followed out, would make him a selfish
person. Adults who are justly accused of being selfish are persons
who have never fully profited from their contact with their fellows,
nor have they learned how to suppress adequately their own personal
desires and demands.
Selfishness is a relative term. This is due to the fact that
individuals differ from each other widely in the matter of natural
endowments. The standard of measure used in judging selfishness in
people is both individual and social. Most frequently the charge of
selfishness is lodged because an individual is not as unselfish as the
group in which he most often appears, but in fairness he must also be
judged with an eye to the intensity of his native egoistic impulses.
From this point of view, what may be selfish in one person is not
selfish in another.
The misunderstanding of children in interpreting their apparent
selfishness is very easy. The traditions of the home may have
accentuated the natural propensity to care for their own interests
beyond that which would have been the case had they had other
surroundings.
 Furthermore, the known variation in natural endowments, and in
the responses to social influences, require one to be lenient in
passing judgment upon selfish people.
As commonly understood, the selfish Its Nature
individual is one who exhibits an excessive
concern for his own welfare, who tends to regard himself as a little
god, watching every opportunity to satisfy his desires, tastes,
impulses and pleasures. He measures every passing circumstance in
terms of its value to him. Even the occasional acts of kindness which
he renders to another are planned so as to bring him the largest
returns financially or socially.
We must not forget that selfishness is an indestructible instinct of
human nature. On this instinct is deeply engraved the law of self-
preservation. Experience in associating with ones’ fellows shows to
an ordinary person how far he must take precautions in order to
maintain his own welfare, but in the case of a few, as we believe,
results of experience have not given the wisdom which renders them
unselfish.
We are never to forget that the will to live underlies and overtops
all other interests and desires in the life of the individual. No sane
method will attempt to suppress this impulse, for out of it spring all
the impulses that induce the individual to seek his fortune and win
success in life.
For the better understanding of Causes
selfishness in children, it is well to survey
some of the general causes that operate in prolonging selfishness
into later childhood and adult life.
First of all, we mention misconception of one’s actual need. By this
we mean that a child overestimates his need for some object that
interests him. He “wants” it very much, as we say. He is unable, by
reason of his immaturity, to estimate accurately his own necessities
in the case. Another specific cause of selfishness is a wrong estimate
of the value which belongs to the object of his eager desire. For these
reasons he is willing to pay too high a price to satisfy himself with
that which, if he were better informed, he could forego with little
discomfort.
 Again, the attainment of success after long and victorious effort
may beget in one a spirit of selfishness. Not infrequently a student
who has solved a difficult problem after painstaking toil, hesitates to
pass on the fruits of his labor to a classmate. He reasons that the
expenditure of energy which he has suffered is worth too much to be
lightly transferred to another person. Particularly will this be the
case if the sharing of his gain will reduce the lustre of his own glory.
Another particular cause of selfishness, both in adults and in
children, is the transition from poverty to plenty, from obscurity to
prominence, from disesteem to fame. If the father or mother has
recently emerged from some retired station in life, the contrast in the
situation is very sure to be reflected in the life of the younger
members of the family. If the change is from poverty to wealth, the
parents are disposed to be miserly in the expenditure of their money.
This attitude of mind reappears in the child in a refusal to share his
pleasures and privileges with his schoolmates. He carries with him a
caution to see that no one trespasses upon his newly achieved rights.
In our western civilization such extreme transitions are not
infrequent, owing to the freedom of opportunity for all.
Many times people who are not widely acquainted with the world
are selfish because they do not believe in the good will of others. This
state of mind is very often found in young children who have not yet
advanced beyond a sort of savagery in which they regard every man
as a possible enemy. They refuse to give up to their associates
because they do not believe any return will come to them. They fear
that all of their possessions will be ravaged and appropriated, and so
exercise excessive caution in lending them or in making presents to
their friends.
It is not unusual that certain interests of some society, class, or
club, are so vividly conceived as to modify the attitude of the entire
group.
A fraternity or literary society or a senior class in a high school
may hold inflated ideas of their importance, and think necessarily
that school interests should rotate around their welfare. Individuals
who belong to the club or society become intoxicated with this
notion, and exhibit an almost barbaric class-selfishness.
With these and other incentives to selfishness, the situation facing
a conscientious teacher is by no means simple. Since selfishness is a
very intimate trait of character, the question might be raised why a
teacher could take interest in curing children of selfishness. The fault
has been generated very largely in the home, and the cure should,
naturally, be largely a matter of home concern.
Nevertheless the public school teacher Cure
has a large responsibility. He must attempt
to improve the character of the child in every way possible.
Obviously, the cure of selfishness can be had only by associating with
other people. It depends upon the teacher to manipulate these
associations in school so as to aid in reforming character at this
point.
Just as clearly, the more startling instances of selfishness
necessitate care that the rights of other pupils be preserved. This
happens so frequently as to demand no elaborate argument.
The teacher’s concern for the general improvement of the moral
life of the school requires that striking instances of selfishness should
be adequately dealt with.
Lastly, selfishness is a prolific source of other wrongs. If an
administrator can cure a selfish child, he has nipped in the bud a
whole harvest of undesirable actions and immoral deeds.
No teacher would ever think of punishing First Grade
a first grade child in any way whatever for
being selfish. The selfish child is usually an only child or has been
made selfish in his desires, by home training. The teacher can do
much to overcome selfishness. When a pupil enters the first grade,
for the first time, he comes in contact with other children and into
surroundings that are new. This is the teacher’s opportunity. The
chances are that the child will often display selfish tendencies. It is
necessary that the teacher have the child’s confidence, but by this
time it is assumed that the teacher has many avenues already
mapped out by which to get this needed confidence. Then the thing
to do is to teach the child unselfishness each time he displays selfish
tendencies. It will take but a few weeks to effect some change in the
selfish child.
In extreme cases it may be well for the teacher to give the child
something for the express purpose of asking him to share it with his
playmates—candy, pictures or any little, inexpensive article that a
child enjoys.
For example, if the teacher has given candy, she may say, “Now,
break it in two pieces and give one piece to Mary.” When the child
has done so the teacher should approve the act. It will incline the
child away from selfishness for the teacher to say, “You are kind to
give Mary some of your candy.” “I like the way you divide with
others,” or, “You like to give things to others, don’t you?” This last
statement of approval will require the child to reply, “Yes.” This is a
necessary positive reaction of the child and a few trials like this may
overcome his selfishness.
The trait of selfishness, while not very annoying in the first grade,
must be suppressed, for if left to develop, it becomes very annoying
in the upper grades. Nothing seems worse than a selfish pupil in the
grammar or high school. And no one needs an introduction to the
avaricious man of the world who got his first lessons in greed
through selfishness in childhood. For the sake of emphasis, then,
may it be said again that there is no more opportune time to
overcome these undesirable traits in a child, than when he first
enters a new world of acquaintances and experiences in the first
school year.

CASE 124 (FIRST GRADE)

The spoiled child has two dominating characteristics—an intense

selfishness and an insatiable appetite for attention. The teacher’s
problem is therefore two-fold, first, to reduce his self-consciousness
by increasing his interest in the world about him, and, secondly, to
enlist his sympathies for others so as to increase his altruism and
supplant his selfishness with a wholesome socialization.
Karen Gompers was a very bright little Spoiled Child
girl whom adoring parents, aunts,
grandparents and enlisted friends had quite spoiled. She expected
her teacher to give her the constant attention she enjoyed at home,
and resented the fact that Miss Nelson seemed to think each of forty
other children as important as she was.
 “I want to sit by you,” she announced as her class seated itself in
the circle of little chairs. “I like to be here.”
“You can’t sit by me today, Karen. It is Wilson’s and Eunice’s turn.
You may sit in that empty chair over there.”
“But I don’t want to! I want to sit here!” and she stood stoutly by
the coveted chair. All the other children were watching her, and she
was enjoying her prominence in the scene she was creating. Miss
Nelson hated a scene above all things, and prided herself on the
perfect mechanics of her teaching.
“Well, Wilson, suppose you let Karen sit here today—that’s a good
boy.”
“But you promised me I could!” There were sudden tears in
Wilson’s eyes.
“I’ll let you sit here another day, Wilson. Be a little gentleman, and
remember that gentlemen give up their chairs to girls.”
So Karen had her way because she had learned the despotism of
the selfish, who secure their ends by sheer insistence. Wilson lost his
faith in his teacher’s word, which did not tend to make him a
gentleman, and Miss Nelson proved herself a coward in consenting
to sacrifice Karen’s good to her own dislike of a conflict.

CONSTRUCTIVE TREATMENT

There are occasions when a definite issue for the mastery occurs in
the school-room, and this was one of them. Miss Nelson had no right
to break her promise to a docile and obedient child, and reinforce the
habitual selfishness of a spoiled one. She should have insisted that
Karen take her turn with the rest, and if Karen had stormed it would
have given her a good opportunity to show her that her usual
methods would not work in school. The angry storming of a spoiled
child is usually done with an alert eye to the effect produced on the
audience; therefore, if Karen had wept and wailed, she should have
been carried out into the hall, where she might have been left in
lonely state to recover her good temper. Usually one or two such
trials convince a spoiled child that he has met his match, and if such
children are followed by tactful guidance, and especially if attention
can be diverted away from themselves, the worst-spoiled children
can in time be thoroughly socialized.

COMMENTS

In every case, the object of the teacher’s treatment is to show the

child that he must conform to the conditions of the social group he
belongs to, instead of fixing conditions to suit himself. She should
remember, however, that real unselfishness has not been attained
until the child voluntarily surrenders some fancied good. Coercion
may sometimes be a stepping stone in leading a child toward the
goal, but it is only a stepping stone. True unselfishness requires that
the child himself deliberately make the choice that crowns another
with the happiness that he desired for himself.

ILLUSTRATION (KINDERGARTEN)

Elmer Bronson, an only child, had a Substitute

difficult task in adjusting himself to his Altruistic Ideal
social environment when, at the age of four, he entered the public
school kindergarten in Grand Rapids, Michigan. At home all
playthings had been his, with none to molest or take away. Moreover,
as the grown-ups in his home were very indulgent, practically all
objects that he desired to have were placed at his disposal.
But at school a new order seemed to prevail. Elmer not only was
not allowed to appropriate many interesting looking objects that lay
about on desks and tables, but at times he was not even permitted
unrestricted handling of his own things. The situation was
perplexing. He couldn’t make it out.
Miss Melbourne, Elmer’s teacher, comprehended the conditions of
the problem better than he did. She perceived that Elmer, as yet, had
no understanding of the meaning of ownership, nor had he received
any training whatever in the recognition of the rights of others. She
must begin at the foundation.
To that end she utilized all sorts of games, stories and dramatic
plays as a means for teaching these two lessons, but that part of the
program which seemed to captivate Elmer more than any other was
the singing of “The Soldier Boy.”
The delightful part of it was that as the song was sung the children
marched about the room wearing paper caps of red, white and blue,
and each, as he marched, was presented by his teacher with a flag to
be proudly borne over the right shoulder. Who could fail to be
patriotic and generous under such stimulating conditions!
One day Elmer spied a toy boat on the desk of one of his
classmates, Freddie Buzzell. Elmer immediately appropriated it.
“Don’t take my boat,” said Freddie.
“’Tain’t yours. It’s mine,” was the reply.
Naturally, Freddie sprang to the defense of his property rights.
Elmer insisted upon the principle of possession as proof of
ownership. Thus the battle was raging when Miss Melborne entered
the room. Knowing Elmer’s individualistic tendencies, she was not
long in getting at the cause of the quarrel.
“Come here, Elmer,” she called from the desk. Elmer came
reluctantly, still holding the toy boat. Miss Melborne picked up one
of the red, white, and blue caps on the table.
“Who are the boys these caps were made for, Elmer?”
“Sojer boys.”
“And what sort of boys are they?”
“Those ‘whose hearts are brave and twue.’”
“Now, Elmer, soldiers who are ‘brave and true’ have to fight
sometimes but do they fight in order to get something they want
themselves, or do they fight to take care of other people?” This was a
pretty hard question for Elmer to think out fully. He looked
thoughtful but did not answer. Miss Melborne tried a more concrete
form of question.
“We would not like to have any one march with the ‘soldier boys’
this afternoon who takes things away from other children, would
we?”
Elmer looked very sober, but he shook his head. Miss Melborne
followed up the advantage she had gained by adding, “What would a
soldier boy ‘whose heart is brave and true’ do, if he had in his hands
something that belonged to another boy?”
 Elmer looked hard at the toy boat for a full minute, then slowly
walked over to Freddie’s desk and carefully placed the boat on it.
“That’s my brave soldier boy!” said Miss Melborne,
enthusiastically. “That’s the kind of boy to wear the soldier cap!” and
she placed it on his head, adding, as she did so, “You may wear it,
dear, till the school bell rings.”
The idea of protection of the rights of others had been substituted
for that of selfish possession. Approval had crystallized the
experience into an attitude of mind. Many reminders of the soldier
boy, “whose heart was brave and true” and who lived for others
instead of self, were necessary before the most selfish child in the
class became one of the most unselfish, but each application on the
teacher’s part of the principles of substitution and approval made the
meaning of the words more explicit to Elmer and the habit of self-
sacrifice more firmly fixed.

CASE 125 (RURAL SCHOOL)

Not infrequently it happens that the selfish child has a continual

example of selfishness before him in his own parents.
Not far from the rural school house in Parental
District Number 10 was the fine residence Example
of Mr. Allen, one of the directors of the school. His rearing of
thoroughbred stock had made his name known throughout the state
and had added thousands to his bank account. When his little son,
Homer, started to school for the first time, he was oversupplied with
pencils, erasers, tablets of all varieties, penholders, stencils, paints,
colored crayons and every known aid to first grade work.
Attending the same school was a large family of very poor children
named Perkins. The Perkins’ children were poorly, but cleanly, clad
in the cheapest of clothing. They had only a few of the necessary
textbooks and half of a lead pencil was made to serve two of the
family, the parents reasoning that two of them wouldn’t surely need
lead pencils at the same time. Joseph and Clarence Perkins were in
the first and second grades, respectively. They had the third of a lead
pencil to be used in common and a piece of a broken slate (with a
two-inch pencil) to be used instead of a tablet.
 Miss Shuttlesworth, a young teacher, felt truly sorry for these two
bright, little boys because they were thus handicapped in their work,
and she allowed them to borrow from other children during periods
when both should be writing at once.
She even fell into the habit of saying, “Joseph, borrow a pencil
from Homer and put your problems on this piece of paper.”
Generous and kindly herself it did not occur to her that Homer was
reluctant to loan one of his many pencils.
One day Laura Manning, a sixteen-year-old pupil who came past
the Allen farm on her way to school, said to Miss Shuttlesworth,
“Mrs. Allen said to tell you she would like to have you come and see
her soon.” Miss Shuttlesworth foresaw from Laura’s manner of
delivering the message that the errand would not be a pleasant one.
She had evidently offended Mrs. Allen in some way, but how she
could not conceive. She had never been in the Allen home nor had
she ever seen Mrs. Allen.
As soon as school closed she made her way to the Allen residence
and was not surprised to have Mrs. Allen greet her coldly and
haughtily, boldly glaring at her and beginning a speech something
like this: “I want you to understand that Homer is not to lend
anything of his to the Perkins’ children. We are able to buy anything
he needs but we don’t intend to buy for the whole school.” Having
more than exhausted this subject Mrs. Allen went on to state that
Homer’s seat must be changed because his desk was defective in
some way. Miss Shuttlesworth had not noticed that Homer’s desk
was different from the others.
She was a young teacher and so was quite overawed by Mrs. Allen’s
angry, commanding tones. She changed Homer’s seat and supplied
the Perkins’ boys with working material herself. She made no effort
to change Homer’s attitude of superiority toward the Perkins’ boys.
His selfishness only increased under his mother’s management.

CONSTRUCTIVE TREATMENT

When children are not supplied with the necessary equipment for
their work and are too poor to buy for themselves make an appeal to
the board of education asking them to purchase the material needed,
which material should be considered the property of the school and
left there from year to year. Most states require that the school
furnish books and equipment for all who are unable to buy them.
Show by your own example that poor people are just as desirable
for companions as rich ones, other things being equal. See to it that
the children of poor parents be made to forget, while at school, that
they are different from others. See to it that democracy reigns on the
playground.
Supervise all play.
Do not foster the borrowing habit.

COMMENTS

If children are unable to buy books, allowing them to borrow daily

is a source of annoyance to both borrower and lender. Besides it daily
emphasizes the contrast in the financial condition between the richer
and the poorer. This is wrong. It fosters haughtiness in the one and
undue humiliation in the other. While you are supervising play you
can easily manage to have the neglected children drawn into play and
even chosen for the enviable parts in the games. It largely depends
upon the teacher’s influence whether the public school is a leveler of
false barriers or a hotbed where selfishness is cultivated.
The borrowing habit, if fostered even among children of equal
rank, teaches a disregard for the property rights of others. Americans
are especially lax in their thought and behavior relative to property
rights, and the public schools can do the nation a great service by
giving its children correct notions concerning appropriation without
ownership, and in selfishness as contrasted with altruism, in both
rich and poor. The rich often enjoy display and the poor retaliate by
vandalism. Both wrongs are the outgrowth of selfishness.

ILLUSTRATION (RURAL SCHOOL)

Margaret Blake lived not far from the Invoking Fairies

Lone Star rural school. Her father had
bought much land years before which had so increased in value that
he was very rich. Many people in the Lone Star district were tenants
on his farms. Margaret’s mother taught her that she was better than
other children and must not “mix” with them more than absolutely
necessary. As soon as she was old enough she was to go to a “select”
school of her own “class” of people.
Miss Coleman saw the situation the first day of school. Margaret’s
selfishness was manifested by her selection of the best seat, the
display on her desk of numerous and costly aids for her work, her
haughty demeanor and her frequent references to what her mother
said she need not do. Whenever she spoke of her mother’s wishes she
emphasized the “I” in a way to show her difference from others.
Miss Coleman knew that the happiness of Margaret as well as of
her other pupils depended upon eradication of the rich child’s
selfishness. She made a special study of the effect of various attempts
to accomplish this end. She told a story of an unselfish child. This did
not seem to appeal to Margaret. She tried another story on the
advantages of wealth in terms of ability to serve others. This was
nearer the mark. After thus finding the correct avenue of approach
Miss Coleman often said something like this to Margaret: “How
fortunate you are in having some things which these other children
cannot afford to have. How would you like to play you are a fairy and
get a new First Reader for little Wilbur Tomlinson, who has no book,
and just leave it on his desk with his name in it, and not tell him who
gave it to him. I’ll help you pay for it, for I want to get fun out of it
too.”
Or, again, “Let’s think what we might plan to do secretly for any
child in the room who really needs something we can give. We’ll be
good fairies again.”
Margaret took a new interest in other children. She soon began to
like to go to school. She enjoyed playing with the other pupils and
loved and honored Miss Coleman.

CASE 126 (FIFTH GRADE)

Florence Crane attended school in Displaying Fruit

Michigan. She lived on a fine fruit farm
where during the fall one variety of peaches, grapes or pears followed
another and when these had all been sold choice apples followed in
season. So it happened that choice fruit was always a part of
Florence’s lunch. This fruit was displayed on her desk and tempted
many a child’s eyes away from school tasks. Miss Bush, the teacher,
requested all of the children to keep their lunches concealed and
away from their desks. Still at recess time Florence had a little group
of children around her watching her eat her luscious fruit. Miss Bush
could scarcely endure the sight of the hungry eyes devouring every
bite with Florence.
One day she was especially tired and without forethought said,
“Florence, you shall not bring another piece of fruit to school unless
you bring enough for all of the girls.” Imagine Florence’s indignation
which was not much greater than that of her associates.
When the girls discussed this together on the playground a little
later Florence said, “I’ve a right to bring whatever I please t’ eat.”
Ethel Green, spokesman for the rest, declared, “Teacher’s crazy.
We don’t want anybody to bring us lunches. If we hain’t got enought
to eat we won’t ask her to give us anything.”
The girls had talked about the matter until the atmosphere of the
school-room was that of slumbering rebellion.
That night when Florence told her parents what Miss Bush said
there was much indignation and a long discussion which ended in a
decision to have Mrs. Crane visit Miss Bush at the schoolhouse next
day. On her way there Mrs. Crane stopped to discuss the situation
with Mrs. Green, whom Ethel had informed of the previous day’s
talk. Mrs. Green was very angry and offered to go with Mrs. Crane to
the schoolhouse.
The situation was very awkward for Miss Bush. She was reluctant
to say in the presence of Mrs. Green that the other girls were always
hanging around Florence watching her eat her fruit and yet she had
to justify herself in some way. The mothers took advantage of Miss
Bush’s embarrassment, assuming that it showed guilt and even
accusing her of giving the command to Florence on the previous day
in order that she herself might be given fruit. The conference ended
with the remark from Mrs. Green, “If you’re hungry yourself, say so,
but don’t beg vittles for my children.”
 Miss Bush’s joy in her work in that school was ended. The girls
might have forgotten the incident but the mothers whenever they
met revived the feeling of anger against Miss Bush.

CONSTRUCTIVE TREATMENT

Miss Bush was too superficial in her original treatment of this case.
She had had ample time to think out a workable plan that would
have caused no friction.
After having all food removed from the desks she might have asked
the pupils to find appropriate seats in which to eat their lunches.
After lunch time she should have led the way to the playground
where all else than play would be easily forgotten.
From time to time short talks on manners should be given to the
whole school.

COMMENTS

It is inexcusable for a teacher to give angry or even

unpremeditated treatment to a case that has been developing for
some time. Miss Bush touched upon a very serious question when
she gave commands concerning what the children had to eat in their
lunches. In her talks on manners the teacher can easily place special
emphasis upon such phases of the subject as are most nearly related
to the habits of her pupils. These general remarks can hurt the
feelings of no one, since they are given to the entire school.
The part that unselfishness plays in what is usually termed good
manners can thus be clearly brought out. Some teachers ask their
pupils to learn the following couplet in this connection:

“Politeness is to do and say

The kindest thing in the kindest way.”

ILLUSTRATION (SECOND GRADE)

 Tommy Holbroke’s father kept a small Eating Candy
candy store in Brighton and Tommy often
carried candy to school with him. This he ate with a great show of
enjoyment in the presence of a group of onlookers. Miss Dean, his
teacher, noted the conditions and appreciated its inevitably baneful
effect upon Tommy’s disposition. Accordingly she visited his mother
and first told her of Tommy’s sunny temper and studious habits.
Then she tactfully led the subject to the boy’s health and food. In
talking of the candy she said, “Of course we must guard Tommy’s
health and his disposition too.” Then she explained that she greatly
feared that his bringing candy to school would make him selfish
because of course it enabled him to have and not share what he knew
others wanted. She suggested that Tommy be given his candy
directly after his meals and at no other time. The double appeal in
behalf of the child’s health as well as his character caused the mother
to follow Miss Dean’s advice. Occasionally, however, on “special
days” or when the children had a “birthday party,” Tommy’s mother
gave him a bag of candy to take to his teacher with the words, “Tell
Miss Dean to please give it to all the children.” So Tommy learned, in
time, the joy of sharing with others.

CASE 127 (EIGHTH GRADE)

The grade schools in the suburbs of one Selfish Play

of our largest cities give special attention to
outdoor play. They even require that the children stay on the school
grounds at least fifteen minutes after the school proper is closed, and
play games there. They encourage the playing of ball by the girls and
are anxious to have them interested in the game.
In one of these schools the principal, Mr. Warren, went to the
eighth grade rooms and gave the girls a talk on baseball. He
advocated that the girls in each eighth grade room elect by ballot a
baseball team and that these teams practice ball with the earnest
expectation of being able eventually to conquer any other eighth
grade team in the suburb. After school a ballot was taken and those
receiving the highest number of votes were considered elected on the
team.