BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of long-term 
cardiopulmonary bypass used to treat infants, children, and adults with 
respiratory and/or cardiac failure despite maximal medical therapy. Mechanical 
emergencies on extracorporeal membrane oxygenation (ECMO) have an associated 
mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and 
critical thinking skills necessary to manage ECMO emergencies is essential to 
patient survival. Traditional training in ECMO management is primarily didactic 
in nature and usually complemented with varying degrees of hands-on training 
using a water-filled ECMO circuit. These traditional training methods do not 
provide an opportunity for trainees to recognize and interpret real-time 
clinical cues generated by human patients and their monitoring equipment. Adult 
learners are most likely to acquire such skills in an active learning 
environment. To provide authentic, intensive, interactive ECMO training without 
risk to real patients, we used methodologies pioneered by the aerospace industry 
and our experience developing a simulation-based training program in neonatal 
resuscitation to develop a similar simulation-based training program in ECMO 
crisis management, ECMO Sim.
METHODS: A survey was conducted at the 19th Annual Children's National Medical 
Center ECMO Symposium to determine current methods for ECMO training. Using 
commercially available technology, we linked a neonatal manikin with a standard 
neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit 
were placed in a simulated neonatal intensive care unit environment equipped 
with remotely controlled monitors, real medical equipment and human colleagues. 
Twenty-five healthcare professionals, all of whom care for patients on ECMO and 
who underwent traditional ECMO training in the prior year, participated in a 
series of simulated ECMO emergencies. At the conclusion of the program, subjects 
completed a questionnaire qualitatively comparing ECMO Sim with their previous 
traditional ECMO training experience. The amount of time spent engaged in active 
and passive activities during both ECMO Sim and traditional ECMO training was 
quantified by review of videotape of each program.
RESULTS: Hospitals currently use lectures, multiple-choice exams, water drills, 
and animal laboratory testing for their ECMO training. Modification of the 
circuit allowed for physiologically appropriate circuit pressures (both pre- and 
postoxygenator) to be achieved while circulating artificial blood continuously 
through the circuit and manikin. Realistic changes in vital signs on the bedside 
monitor and fluctuations in the mixed venous oxygen saturation monitor were also 
effectively achieved remotely. All subjects rated the realism of the scenarios 
as good or excellent and described ECMO Sim as more effective than traditional 
ECMO training. They reported that ECMO Sim engaged their intellect to a greater 
degree and better developed their technical, behavioral, and critical thinking 
skills. Active learning (eg, hands-on activities) comprised 78% of the total 
ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). 
Instructor-led lectures predominated in traditional ECMO training.
CONCLUSION: Traditional ECMO training programs have yet to incorporate 
simulation-based methodology. Using current technology it is possible to 
realistically simulate in real-time the clinical cues (visual, auditory, and 
tactile) generated by a patient on ECMO. ECMO Sim as a training program provides 
more opportunities for active learning than traditional training programs in 
ECMO management and is overwhelmingly preferred by the experienced healthcare 
professionals serving as subjects in this study. Subjects also indicated that 
they felt that the acquisition of key cognitive, technical, and behavioral 
skills and transfer of those skills to the real medical domain was better 
achieved during simulation-based training.