At the Tactical Trauma 24 conference in Sundsvall, Sweden, St Emlyn’s hosts Iain Beardsell and Liz Crowe had the opportunity to speak with Alice Hutin, an emergency physician with Service d’aide médicale urgente de Paris (SAMU), about her work in pre-hospital emergency care, specifically in employing extracorporeal cardiopulmonary resuscitation (eCPR) for refractory cardiac arrest. This post explores Alice’s insights on integrating eCPR into daily practice, her team’s operations in complex urban settings, and her groundbreaking research on total liquid ventilation and therapeutic hypothermia. Health professionals working in emergency medicine will find valuable learning points in her pioneering approaches to improving patient outcomes in critical care.
Listening Time – 20.59
What is eCPR and How is it Applied in Paris?
In Paris, eCPR is more than a cutting-edge treatment; it is now embedded in the daily work of SAMU’s mobile intensive care units. Alice describes eCPR as an established intervention for patients in refractory cardiac arrest, a process SAMU can initiate in pre-hospital settings—something yet to be widely adopted in other regions and currently something it is hard to imagine in the UK.
ECPR was first established in France at the Service d’aide médicale urgente de Paris in 2011, and since then, it has expanded to several other cities. The service is based around the mobile intensive care unit, an established part of French pre-hospital care. These units can provide all equipment required as though they were in-hospital to either ‘see and treat’ on scene or ‘scoop and run’ to take the patient to hospital. The mobile eCPR team consists of an anaesthetist-intensivist or emergency physician, an anaesthetic nurse and a paramedic. This team is available 24 hours a day, 7 days a week. The eCPR team is dispatched to all witnessed cardiac arrests alongside the MICU and a basic life support unit. The ECPR team is then stood down if there is ROSC or no indication for ECPR. The objective of the ECPR team is to establish patients on an ECMO circuit within 60 minutes of the witnessed arrest and convey them to hospital for further care.
The Step-by-Step eCPR Process
In SAMU’s dispatch system, when an emergency call indicates a potential cardiac arrest, a highly orchestrated response begins. First responders, often firefighters or Basic Life Support (BLS) teams, are sent to initiate immediate cardiopulmonary resuscitation (CPR). Alongside this, an Advanced Life Support (ALS) team and, if indicated, the eCPR team, are dispatched.
“The goal is to ensure that eCPR is delivered within the right timing to the right patients,” Alice emphasises. The eCPR team arrives equipped for on-scene cannulation if they determine the patient has a chance of neurologically intact survival.
In her description, Alice highlights that the eCPR team comprises an emergency physician or ICU physician, an anaesthetic nurse, and a paramedic. Within 20 minutes of cardiac arrest, the team assesses eligibility based on various criteria, including the duration and quality of bystander CPR, comorbidities, and overall prognosis.
Eligibility and Decision-Making in eCPR
Determining eCPR candidacy is a critical and sometimes challenging aspect of the process. Alice and her team are stringent about who receives eCPR, as the procedure is invasive and resource-intensive. She explains, “If the patient is likely to achieve neurologically intact survival, we proceed with cannulation on-site.”
This includes retrieving equipment from a dedicated vehicle, setting up a sterile environment, and performing cannulation on the scene. Alice notes that the physical environment—whether it’s a crowded area like the Louvre or a Metro station—presents unique challenges, requiring her team to manage both the patient and the bystanders around them. Local police and firefighters are often essential partners in securing the scene.
Facing Rejection: Communicating Non-Candidacy for eCPR
Not every patient meets the stringent criteria for eCPR. Hutton notes that communicating a decision not to proceed is as crucial as the procedure itself. This involves explaining to both the on-scene team and any accompanying family members why eCPR might not be suitable, particularly when the public’s perception of eCPR’s benefits may be optimistic due to media exposure.
“It’s about explaining why we believe that complications and prolonged downtime would limit recovery,” Alice explains, adding that the communication skills required are unique and essential in her team’s training.
Transport and Post-Intervention Care Pathways
In most cases, patients who receive eCPR bypass the emergency department entirely, heading directly to a catheterization lab for further investigation of potential coronary occlusions or occasionally to the CT suite if a pulmonary embolism is suspected. This streamlined approach underlines SAMU’s commitment to efficient, targeted care for cardiac arrest patients.
“In Paris, we bring the ICU to the patient,” Alice describes. “It’s all about placing the patient in the right setting, which often means bypassing the ED entirely to get them where they need to be.”
The team’s commitment extends to around-the-clock service, available 24 hours a day, seven days a week, although nighttime coverage sometimes involves the paramedic picking up the on-call physician from home. Despite this, they complete 60 to 80 eCPR cases annually, with a neurologically intact survival rate between 20-30%, a promising figure considering the severity of cases they manage.
A Glimpse into the Future: Therapeutic Hypothermia and Total Liquid Ventilation
Alice’s PhD research delves into an innovative method of therapeutic hypothermia, an area of interest due to its potential to improve post-cardiac arrest outcomes. Therapeutic hypothermia aims to cool the body and limit post-cardiac arrest syndrome, potentially improving neurological recovery. Traditional approaches have had limited success, partly because cooling patients rapidly enough after cardiac arrest has proven challenging. Hutton’s research focuses on total liquid ventilation—a novel technique that could achieve rapid cooling by using the lungs as a cooling surface.
How Total Liquid Ventilation Works
Total liquid ventilation involves using a dedicated ventilator that circulates a specialized cooling liquid called perfluorocarbon through the lungs. This approach aims to cool the body within 10-15 minutes of initiating ventilation, meeting the crucial 60-90-minute window that Hutton and her colleagues believe is necessary for therapeutic hypothermia to be effective.
“This ventilator uses perfluorocarbon to exchange gases just like air, but it’s chilled, turning the lungs into a cooling surface,” Hutton explains. This rapid cooling technique could potentially limit post-cardiac arrest syndrome and improve survival rates among patients with refractory cardiac arrest.
Although currently a large in-hospital device, Hutton hopes that technological advancements may eventually make total liquid ventilation portable, enabling pre-hospital applications alongside eCPR.
The Importance of Team Debriefing and Shared Decision-Making
For high-performing teams like Hutton’s, regular debriefing sessions are vital. Whether after successful resuscitation or a decision not to proceed, team members have an opportunity to reflect on the cases, discuss emotional and procedural aspects, and refine protocols.
“We discuss everything—age, CPR quality, the conditions on the scene—because hearing it out loud sometimes solidifies the decision-making process,” Hutton says. The shared responsibility fosters a culture of open communication and continuous improvement, especially given the stressful nature of pre-hospital resuscitation.
Key Takeaways for Emergency Medicine Professionals
For emergency and critical care professionals, Hutton’s experiences offer several key takeaways:
- Integration of eCPR into Daily Practice
eCPR is no longer reserved for hospital settings in certain parts of the world, and Paris offers a model where it can be integrated into pre-hospital care with structured dispatch protocols and multidisciplinary teams. - Importance of Stringent Criteria for eCPR Eligibility
Identifying the right candidates is crucial for the success of eCPR, with an emphasis on including only those with a strong chance of neurologically intact survival. - Role of Therapeutic Hypothermia in Post-Arrest Care
Although therapeutic hypothermia is still a subject of debate, the rapid cooling potential of total liquid ventilation represents a promising frontier. Future devices may allow for its deployment alongside eCPR, increasing the likelihood of preserving neurological function. - Value of Communication and Decision Transparency
Effective communication is essential, particularly in cases where eCPR is not an option. Clear, compassionate explanation to both colleagues and family members helps ensure understanding and aligns expectations. - Debriefing as a Core Practice
Regular debriefing enables teams to reflect on their performance, make collective decisions, and support one another in this high-stakes field.
Conclusion: Shaping the Future of Pre-Hospital Resuscitation
Alice Hutton’s insights from Paris demonstrate how an advanced, mobile approach to critical care is possible and sustainable in pre-hospital settings. By adapting to the environment and advancing technology, SAMU’s eCPR and research into therapeutic hypothermia continue to push the boundaries of what’s achievable in emergency medicine. With hope, Hutton’s pioneering work in total liquid ventilation may one day be the standard, taking the emergency room to the patient and expanding the horizons of survival in pre-hospital cardiac arrest. For health professionals worldwide, her work serves as both an inspiration and a roadmap for what future emergency medicine systems might aspire to achieve.
Podcast Transcription
Welcome to the St Emlyn’s podcast. I’m Iain Beardsell.
And I’m Liz Crowe.
And we’re at Tactical Trauma 24 in Sundsvall, Sweden. It’s an absolute pleasure to have a French colleague with us on the podcast, Alice Hutton, who works with SAMU in Paris, who are famous for being able to put eCPR on in the Louvre.
But hopefully, Alice, you’ll tell us a bit more behind the service and some of the frontiers of your PhD research. But before we start, could you just introduce yourself to our listeners?
Thanks for having me. It’s a real pleasure to be here. so my name is Alice Hutton. I’m an, emergency physician in Paris. I’ve been working now for about 10 years and I actually did do a PhD,experimental research on refractory cardiac arrest using eCPR and also, I worked on, therapeutic hypothermia, for post ROSC patients,
We do lots of day to day stuff in emergency medicine, but sometimes getting excited about what’s coming next is really interesting for all of us.
And it sounds to me like your PhD was the future. where would you say we’re at with post ROSC care when it comes to eCPR, and then maybe we could even talk about the other bit of your PhD to do with total liquid ventilation?
eCPR is, I would not say the future for us now because it’s a day to day, treatment that we are able to deliver in the pre hospital setting, in Paris and outside the city of Paris. But it’s really something, fascinating to be able to, organise patient care to make sure that, eCPR is delivered within the right timing to the right patients, and making sure that all the people we work with, in the pre hospital setting work with us, whether it be, the firefighters, the mobile ICU teams that are our, um, ALS teams in Paris, and making sure everyone is okay, with what we do and we decide together if patients are eligible to eCPR or not. It’s a real challenge, but, I would say that’s more day to day basis than the future of emergency medicine.
We’re not seeing this in the UK as much, perhaps, as we’d like.
And some of us would dream about the day where we can offer eCPR. Could you possibly just talk us through this day to day event and how it actually occurs that somebody gets from having a cardiac arrest, in Paris, to being on pump. What does that take? And how do you get to what you call day to day management now?
In Paris, now, nowadays, if you if we get in the semi regulation center, the dispatch center, if we get a call for assistance, we immediately dispatch, community response. If, for any chance there is someone with an app of a cardiac arrest bystander app available to be able to, assist immediate bystanders with CPR, we dispatch them.
We dispatch our BLS teams who are the firefighters. Our mobile ICU team, which is the ALS team. And if we have any reason to believe that the patient might be an eCPR candidate, we will dispatch the eCPR team, at the same time, to make sure that we are on the scene early, to evaluate the patient, assess, the, chain of survival that It’s been set up for this patient and see if the patient is indeed a candidate.
And if the patient is in refractory cardiac arrest, then we will go ahead with, cannulation on the scene with all the equipment that we have with us.
So tell us a bit more who’s on that ECMO team, who’s being dispatched to the scene and what would you actually go about doing when you arrive?
So in the ECMO team, we have three people, an emergency physician or an ICU physician, an anaesthetic nurse, and a paramedic. The paramedic is the one getting us to the scene. We usually get there,within 20 minutes of the initial cardiac arrest. Sometimes it’s at the same time as the mobile ICU, sometimes it’s afterwards. And the idea is that we try to collect as much information as we can on the the patient, comorbidities of the patient. If we have the information,when did the cardiac arrest occur? Was there any bystander CPR? What was the quality of CPR until we get there?
And by the time we are there, within 20 minutes, we need to decide if the patient is a candidate or not. and we decide at that time if we cannulate or not.
You go through all of that, they’ve met your inclusion criteria, which I’m guessing are quite strict. You only want to put people on pump if you think they’ve got a chance of surviving.
What happens next?
if we decide the patient is, potentially, a neurologically intact survival if we deliver eCPR, then we get, all our equipment, from our dedicated vehicle, which means the machine, the cannula, the wires. We dress, in sterile conditions to make sure that we limit infection or complications, and then we, go ahead with the cannulation. We’ve now had a quite a bit of experience in cannulation itself. So it’s not a, it’s not something that we find complicated in itself, but it’s more dealing with the scene and dealing with the people there. If you’re in a crowded place like the Louvre that you mentioned earlier or in the Metro or in a public area, you need to be able to secure everything because it is taking the hospital to the patient, but in an environment that can be hostile. So you need to deal with the patient, deal with the cannulation, but also deal with the whole scene management.
And do you put up curtains? Do you put up some sort of shield so that people are not observing?
We can. we don’t actually mind people observing as long as they’re not filming or interfering with the scene which is quite common when we’re in public places. So we have the police there. We have the firefighters there to secure the scene, whether it be physically or visually.
That’s quite a different skill set, from doing that in the controlled environment of the hospital. What additional skills do you have to teach, a high performing team like that? My second question is, what happens if you get there, assuming that most people are accompanied by a loved one, and the decision is no? Do you take the person back to hospital? Do you declare death? Do you say they’re not eligible for ECMO, but we’ll take them back to intensive care? Like, how is that managed?
So to answer your first question, I, I think, we are trained to do the specific, eCPR cannulation, but being, for most of us pre hospital physicians, we’re used to being outside of the hospital and dealing with that environment.
For us, it’s just adapting to another environment that we are used to. So we know that we need to manage the scene, be as sterile as possible, just do what we have to do, wherever it be, whether it be on the floor or on a gurney. And to answer your second question concerning saying no,
the family is one thing, but dealing with the crews, the teams that are there who are waiting for us is also an issue, I find. To get to the scene and in the end tell everyone, we’re here, but we’re not going to do eCPR for this patient because, the patient is not a good candidate, so it takes quite a bit of explanation, and dealing with the family is something that, is, quite difficult as well because,now that it’s been,in the press, there are people who know who we are and who know we’re an extra team getting to the scene, and some have heard about us, and it does need some explanation to tell the family.The downtime has been too long, or,whatever went wrong,makes that we think that, your husband or your wife is not a candidate and all the complications that could occur if we were to go to eCPR would only make it more difficult and we have quite a lot of data, saying that if we were to go with the CPR, the prognosis would not be good. So it’s just about explaining to everyone why we take that decision. Although it would be easier to go to eCPR and just, take the patient to the hospital and let the in hospital people deal with complications, deal with the, patient dying within minutes or hours, but, yeah, it’s all about communicating,
Do you guys debrief?
We definitely debrief within our team. We debrief within the eCPR team. although in the eCPR team, some of the people who work with us are there just because they were posted there or they were just,on the team that day.
But we tend to debrief with the physicians from the team who are basically all eCPR believers. And we debrief after all the cases, especially the difficult cases, but we also tend to take decisions together if needed. So we will always have someone to call if we have difficulties saying yes or no.
And sometimes just, saying things out loud, saying what age the patient is, how the CPR went, and, sometimes just hearing yourself ,makes it more easy to take that decision.
So you decide to get the patient onto the pump and you’re on the floor or you’re in the back of the ambulance and you take them into hospital.
And I’m an in hospital emergency physician most of my time. What happens next?
Most of our patients are taken to the cath lab, because we know that, a lot of these patients have coronary occlusion as a cause of cardiac arrest. So we take them systematically to cath lab, except if we think for some reason a PE could be a diagnosis.
In that case, we would go to do a CT scan first. but otherwise, we go to the cath lab and then back to the ICU,for post cardiac arrest care and the whole post cardiac arrest management.
So most of these patients bypass the emergency department completely? Oh, definitely.
Which is the system in France.
The whole idea behind the SAMU and the dispatch centre is that we have mobile ICUs who go to the patient, and if we can, we bypass the emergency room to take the patient to the ICU, to the cardiac, ICU or to the OR if necessary. But we don’t take these patients to the E.R… Definitely not.
And is that only certain hospitals where you’re going to, or is it to the hospital that’s nearest to you?
We decide which is the best hospital to go to, so if it’s further out, it doesn’t matter. We will go to the best, destination for the patient. So if the closest hospital does not have a cath lab or an ICU, then we will go to the other hospital. It’s all about putting the patient in the right place.
And are you running this seven days a week, 24 hours a day?
Yeah, we are. We used to, have it only during the day at some point. The physician during the day is in the hospital, during the night we’re on call at home, so the paramedic has to come get us.
So it makes, the timing not as good, but definitely we try to have it 24 hours.
And you mentioned this is day to day, how many of these cases have you done, dare I ask, how many have you done yourself, and the service itself, and what’s your success rate?
I, myself, I have no idea, but I’ve been there for 10 years now, almost, and we do 60 to 80 cases per year, Quite a lot, I would say, and the success rate is, the percentage of neurologically intact survival is between 20 and 30 percent, depending on the years, so for very selected patients and we’re hoping to actually get our 10 year of pre hospital eCPR data out soon, So that’s exciting. and I think we’re seeing that in action in other parts of the world as well. for some people, that’s become your day to day. Some people are saying, that’s still very frontier or, something to aim for in the future. we mentioned earlier, though, that you did something very experimental as your PhD.
Can you talk us through that?
We know that therapeutic hypothermia is something that’s been very debated on in the past 10 years. We used to think for post cardiac arrest care that, hypothermia would be good to cool the whole body down and make sure that, post cardiac arrest syndrome would be, dealt with.
And then a lot of studies actually came out and said that, it’s basically useless. The thing is that we are probably cooling patients, in these past studies, not as fast as we should, and therapeutic hypothermia is probably worthwhile within, 60 to 90 minutes of cardiac arrest, or at least of ROSC.
So if you want, this hypothermia to be effective, you need to deliver it very fast after cardiac arrest. Everything we’ve tried in these past few years is not fast enough in bringing temperature down below 34 degrees. So the lab in which I did my PhD, is actually working on, total liquid ventilation, which is a ventilation that uses a dedicated ventilator, which actually,ventilates with liquid.
Dedicated liquid, which is called perfluorocarbon. and these liquids,are actually used to do gas exchanges in the same manner as, the air we breathe. but as the liquid is cooled, the, the lungs are used as a sort of, cooling surface. and the idea is that we use this, device to cool patients or at least the animals that we were delivering this ventilation to was able to cool the animals within 10 to 15 minutes of the onset of this ventilation.
So we actually are able to deliver ultra fast cooling. And this is what is able to limit post cardiac arrest syndrome.
Is this something that may end up going out with you in the eCPR? vans is this the next step?
It is the first clinical study that is going to be done within the months to come normally in Paris, will be an in hospital cooling device because it’s still very, large.
It’s a very large dedicated ventilator that is being developed. but clearly, if we want to cool patients within 60 minutes of cardiac arrest, at some point we’re going to have to be doing this in the pre hospital setting. And I definitely hope to be able to do that within the years to come.
Alice, it’s been fascinating talking to you, just hearing about what is possible. And as you’ve said over and over, this can be a day to day activity and you can be doing this, in a properly working system, and for those of us in the UK who can only aspire to this, hearing you talk about it is utterly inspirational, and the next steps, it sounds like Star Trek to me, but who knows?
Maybe before I retire, we’ll be doing total liquid ventilation. Alice, thank you so much for your time. It’s been an utter delight to talk to you.
Yeah, thank you so much.
Thank you so much for having me.
The Guest – Alice Hutin
Alice Hutin is an emergency physician who has been working at the SAMU de Paris for almost 10 years, specialising in prehospital emergency medicine and acute care. Her clinical activity is divided between the Mobile Intensive Care Unit, the emergency call centre and the prehospital ECPR team. She has a PhD and postdoc in fundamental research on cardiac arrest, more specifically on ventilation during cardiac arrest, refractory cardiac arrest requiring ECPR, and post cardiac arrest care with ultra-fast hypothermia using total liquid ventilation.
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Tactical Trauma
Huge thanks to Fredrik Granholm and all at Tactical Trauma 24 for their very warm welcome and for letting us record this series of podcasts. This is a fantastic conference, and we would highly recommend you check it out when they advertise their next event.
