When the terrorist attacks struck Paris on November 13th, rather than cancel his Paris-bound flight the next day, Dr. Jim Manning suited up and headed to the city whose official motto is “Fluctuat Nec Mergitur” (Tossed But Not Sunk). For a week he observed the EMS system serve as a stabilizing force for Paris in the aftermath of the massacre, and watched as the physician-staffed SAMU de Paris performed novel critical care in the field.
Jim Manning’s first sign of trouble came in the form of a text message.
“Do you see what’s going on in Paris?” asked Shane McCurdy, the lab manager of the UNC Department of Emergency Medicine resuscitation research lab.
It was Friday the 13th of November and Manning, an emergency physician at UNC, had just dropped off two French colleagues at the Raleigh-Durham International airport. They were en route to Paris, a city which, as that Friday evening unfolded, was reeling from a string of coordinated terrorist attacks.
His first thoughts went to his colleagues, who were flying from RDU through Boston to Paris. He feared that they’d get stranded in Boston. Mercifully, he learned that the flights were only slightly delayed, which allowed Manning to move on to his next pressing question: “Am I still going to Paris tomorrow?”
Months prior to the terrorist attacks of the 13th, Dr. Manning had arranged with Dr. Lionel Lamhaut of the Parisian SAMU (Service d’Aide Medicale Urgente) to visit Paris and observe them in action. Specifically, Manning had an interest in learning more about how the SAMU de Paris performed pre-hospital ECMO, a novel approach to extending critical care resuscitation to cardiac arrest patients in the field. Manning has performed cardiac arrest resuscitation research for many years focused on extracorporeal perfusion interventions like selective aortic arch perfusion (SAAP) and ECMO. Riding along with the SAMU offered him an exciting opportunity to see this prehospital ECMO team in action.
Yet there it was that Friday night, on every news channel and every Facebook status update. More than 100 dead and the death toll rising. More than 300 injured, with new scenes of carnage surfacing with each passing hour.
“I was encouraged by some people I know to stay [at home],” said Manning. “No, don’t go; it’s too dangerous.” But the two days spent collaborating in Manning’s lab with his French colleagues had gone beyond the sharing of ideas about SAAP and ECMO resuscitation. They’d shared meals; talked about their hopes for the future.
“These are my friends now,” said Manning. “We had set this up for the purpose of exchange, collaboration in an effort to try to advance resuscitation care. To a certain degree, [deciding whether to go or not] was a philosophical stance: What are you going to do in response to terrorist actions like this? I think the right response is: You keep doing all the things that you do. So the question becomes: If you’re going to pursue something, when are you going to say it’s safe? And so I just kind of thought: Go. Just go. Be there.….stand with your French colleagues and friends.”
And so he did. Manning arrived at 9 o’clock in the morning, Paris time, and the scene that he found surprised and impressed him. It was about 36 hours after the attacks, and Manning decided to stretch his legs and get a feel for the city’s mood. The sky was clear and the temperature was in the 60s. By all normal accounts, it was the perfect day for a walk along the Seine, but given the events of the weekend, Manning found himself on high alert. What he found, however, he described as “a courageous response” by the Parisian people as a whole – the collective decision to not live in fear.
“I started to walk up through one of the parks by the Eiffel Tower and it was really sort of stunning and refreshing to see that people were out. They were on the parks. They were out with their kids. They were out walking with the grandparents. If I didn’t know that this attack had just occurred, I would not have known that anything had happened at all. They weren’t hold up in their houses shaking and afraid. There was clearly an increase in police presence. There was no doubt about that. And there were places where I saw military out and some of them were carrying assault type weapons. But the people were out. I couldn’t help but feel a sense of being inspired and impressed with their response.”
Manning observed a similar, quietly-courageous response from the SAMU emergency responders when he began riding along with them the following morning.
“They were all showing up, doing what they do. All these SAMU doctors who had been on scene that night were still showing up, being SAMU doctors and going out and serving the people of Paris. And I just thought that was striking. Their city’s just undergone this series of attacks. But they just were sort of undaunted.”
Many of the SAMU emergency personnel that Manning rode along with had been part of the initial response the night of the attacks. That night, a sort of “All Call” page went out to all available SAMU doctors who then converged on the SAMU Headquarters at Necker Hospital and then responded as needed throughout Paris based on a coordinated “White Plan” that had been developed and rehearsed for such emergencies.
“Many of them were up all night long. I talked at length to one of them who was one of three doctors that were staffed at a makeshift hospital that was outside the Bataclan. They took care of 50 or 60 patients there. Two or three of them were really injured badly and required critical care.”
“[On that Monday] it was still an environment where you could say: Is it really safe? You’re not really sure. But they were dressed in their SAMU suits and they were there, staffing the ambulances. There was no sense at all that they had decreased their service capability.”
In the end, Manning did get to see the ECMO team in action. After a day of riding along on normal ambulance runs, observing how SAMU personnel respond to typical emergencies, he got to take part in a dedicated pre-hospital ECMO team responding to cardiac arrests. The ECMO team uses a specially equipped response vehicle that is on call for just such occasions. Over the course of five days being attached to the ECMO team, Manning rode along on eight dispatches for cardiac arrests. Five of the eight didn’t meet the ECMO criteria. Of the three that did, two were able to be resuscitated before ECMO could be initiated. That left one patient who fit the ECMO criteria and who could not be resuscitated. This particular patient had a witnessed collapse in a train station, and no life support measures were succeeding when the ECMO team arrived, so the aggressive intervention was carried out in the field, right there in the train station.
As the team cannulated the patient in cardiac arrest and put him on extracorporeal life support, Manning looked up and found himself surprised anew that this was all happening in the corridor of a train station. He thought to himself, “Wow, you can go to this level of interventional support anywhere.”
“Even though I knew that they were doing it already, just to stand there and actually watch it – wow. They’re capable of doing this and doing it fast. In 15, 17 minutes they can have somebody on extracorporeal life support. And once you’ve gone to that level, you then have bought a lot of time to be able to get the patient to some other intervention to try to help save their life.”
Incidentally, by the time the ECMO team had carefully moved the patient up through an escalator and out into the ambulance, he had a return of spontaneous circulation. From there the patient was taken to a hospital and had a cardiac catheterization.
In Paris, when a patient goes on ECMO, they are typically taken to Necker Hospital, whose ICU acts as a central receiving unit for all ECMO patients in the city.
“They have patients there all the time. So they’re regularly taking care of one, two, as many of three post-cardiac arrest ECMO patients; so that they’re very skilled with it because their experience level is high.”
Now that he’s back at UNC, Manning has given a lot of thought to the Parisian system. Is this the way the United States EMS system should go? Would physicians in the field work here? What is the cost/benefit to providing critical care in the field? As is so often the case in medicine, each answer reveals two new questions. For Manning, the only thing certain is that change is on the horizon. Or at least it should be.
“There’s been a tremendous amount of advance in extracorporeal life support technology, like ECMO, where now it’s actually portable. Which poses an interesting sort of question and dilemma for the United States, where we don’t have the same level of training in the field. If this is where resuscitation medicine is moving, if we are going to be moving to much more advanced procedures, how are we going to handle this? At least to begin with, I think we will probably have to begin to look at having some sort of physicians – or certainly more highly trained individuals – in the field who can perform these more complex tasks. And so it’s a real question for the United States with our standard paramedic systems.”
In the end, though, Manning’s biggest lessons from his week in Paris weren’t just about pre-hospital ECMO. He learned – or at least was reminded – of the essential nature of international collaboration. His advice to young doctors? “Open your mind.”
“The world is changing and our capabilities are changing. Technology is much more portable. There are advanced technologies, advanced techniques that are coming around that can be applied in the field. How can we build systems that actually engage physicians as actual direct providers of care and not just in a supervisory or administrative role and to try to look at that, gain experience from that. We need to look to our colleagues in other places who have been doing this for decades and say: This is great. We should learn from you. We should look at how you approach these problems and engage our international colleagues to learn from them and try to figure out how to build the best system here at home.”