In this conversation on Scrubbing In, the medical and operating room innovation podcast, we talk with Linda Mongero and discuss a chance meeting that led her into the perfusion industry and how ECMO has grown exponentially for life-saving, long-term support.

Todd Schlosser: Hello, and welcome to this episode of Scrubbing In, a podcast powered by SpecialtyCare. I’m Todd [Schlosser], and today my guest is Linda Mongero, the VP of ECLS and ECMO services at SpecialtyCare. In this conversation Linda and I discuss a chance meeting that led her into the profusion industry, and how ECMO has grown exponentially for life saving, long term support. Enjoy the conversation.

Thanks for listening to Scrubbing In, my names Todd Schlosser and with me today is Linda Mongero, the VP of ECLS and ECMO services here at SpecialtyCare, and she’s joining us today to talk to us a little bit about what ECMO is and how it’s changing and growing and, of course, talk a little bit about her background. If I can, I’d like to start out with what brought you to sort of the healthcare field in general.

Linda Mongero: Okay, so I was in college and just as I was graduating I was biology and chemistry. I was working summers for my dentist. I had come home for my last summer and he had suggested that I would go to Shady Side Hospital in Pittsburgh and take a look at what they’re doing in cardiac surgery, and that they have these people there called perfusionist’s, and it’s really neat. I said, “Oh yeah, never heard of that.” He said, “Yeah, and it’s a really good field to get into because I live across the street from the guy that owns a big perfusion corporation called Cycore.” I said, “Okay.”

Todd Schlosser: Uh-huh (affirmative), I’ve heard of Cycore.

Linda Mongero: Yeah, exactly, well that was us, you know.

Todd Schlosser: Yeah, yeah, yeah, through the years.

Linda Mongero: 30 years ago, yeah exactly.

Todd Schlosser: Yeah, we’ve evolved, but yeah.

Linda Mongero: That’s exactly what happened and so I did go there and I was fascinated by it, just-

Todd Schlosser: It was your dentist that told you about this?

Linda Mongero: My dentist.

Todd Schlosser: Because he lives next door to-

Linda Mongero: Yeah, across the street.

Todd Schlosser: That’s amazing.

Linda Mongero: I know.

Todd Schlosser: That’s an amazing coincidence.

Linda Mongero: That’s how it happened. Then, I graduated and my mother actually said, “You have to do this, you have to do this.” She knew nothing about it, she, “You have to do this, this is really cool and you need to do this.” I said, “All right, I will apply, I will go and visit.” Then, I got a letter in the mail, and the letter stated, “Linda, please come to a formal interview on this and such a date.” I said, “Oh, I’ll go to the interview.” I go to the interview and it was like-

Todd Schlosser: I’ll just go to the interview [inaudible].

Linda Mongero: I wasn’t reluctant but I was just like this is just something I didn’t plan.

Todd Schlosser: Right.

Linda Mongero: Next thing that happened we get to the interview and there’s about 13 or 14 people sitting around the table, and they said, “Well, welcome to your interview, go ahead and just go ahead and talk.” They had cameras on us and they walked out of the room, the people that were interviewing. We were all sitting at this table like nurses and respiratory therapy, people that wanted to get into perfusion, and that was in 1978. Everybody wanted to be a perfusionist’s, and there weren’t a lot of slots for perfusionist’s and perfusion schools. So, people that had a vast experience in medicine, nurses as I said, respiratory therapists. Others that knew about perfusion in their hospitals said, “I really want to do this.” I knew nothing, I’m out of college and I’m sitting there, so no ones saying anything. We’re all-

Todd Schlosser: You were like, “I talked to a dentist once and he told me to come here.”

Linda Mongero: Yeah, we’re looking at each other and I go, “Oh, well I’ll start. I just graduated from Ashley University in Ohio.” We talked around the room, and the whole while they were kind of interviewing us from another room watching what we were doing. Then, they individually took us out and took us into the OR, which I had already been. Then, we had a psychological interview. A psychiatrist came in, sat down with us one-on-one. What would you do if you killed someone, are you mechanically inclined, you know all those kinds of things. Then, I left there and I walked down to the end of the street and I was like … that was crazy.

Todd Schlosser: Very strange.

Linda Mongero: Crazy interview. I thought well, we’ll see, whatever. I mean, I still wasn’t even like, “Oh, I really want to do this.” But, everybody in that room really wanted to do this.

Todd Schlosser: Really wanted, mm-hmm (affirmative).

Linda Mongero: They did ask one key thing. Would you be willing to relocate. This was in Pittsburgh, Pennsylvania, and everybody that was there already had some families, they were established, they really didn’t want to leave Pittsburgh. That I think launched me to the top of the list, and then I was actually awarded the first position. Then, my mother’s like, “You really have to take this.” I said, “I am, I’m going to do it.” It was a year, and so it just started me-

Todd Schlosser: Yeah, the training program or the school.

Linda Mongero: The school was a year long, yeah. I just thought yeah, I mean really what do I have to lose. It’s in my field and it was so interesting, and so it just launched my career. I mean, I loved it. I fell in love with it and I’ve been doing it ever since.

Todd Schlosser: When you finished school did you immediately get a job as a perfusionist, like a clinical perfusionist?

Linda Mongero: Yup, I took my first job in Cincinnati.

Todd Schlosser: Okay, so you did relocate.

Linda Mongero: Yup, I did.

Todd Schlosser: You worked in an OR for how long?

Linda Mongero: For the last 40 years.

Todd Schlosser: Yeah, so you still do this?

Linda Mongero: Until I came to SpecialtyCare and then I took a position with, Dr. Weinstein asked me to come on board to be the director of education and clinical performance. He said to me, “Linda, you grew one of the biggest programs in the country, I worked at New York Presbyterian Columbia University and I had 30 perfusionist’s.” Which is a really big program.

Todd Schlosser: That is very big, yeah.

Linda Mongero: He said, “But, if you come to SpecialtyCare you can work from home and you have 450 perfusionist’s.” I said wow, so that was like a really key thing for him to tell me, because I said that is, he said you could really possibly change perfusion. I love that challenge. I thought yup. This is a good segue for me into something else, and I was driving into the city for 27 years back and forth every single day, and I got, when I came to SpecialtyCare and I’m working from home I had now 15 more hours in my week.

Todd Schlosser: Just because of the commute?

Linda Mongero: Just, yup.

Todd Schlosser: That’s got to be such a gift.

Linda Mongero: It was.

Todd Schlosser: That’s something that I know because we pay attention to things like what perfusionist’s are looking for when they’re looking for jobs, because as you mentioned when you applied to be a perfusionist or go to perfusionist school, it was such a pursued career.
Linda Mongero: Oh, it was.

Todd Schlosser: It was hard to get into it. Now, it’s sort of the opposite. We need perfusionist’s to join the industry, so we’re actively recruiting them, and some of the things that they’re saying is I Need a better work life balance and things like that. That’s the things that SpecialtyCare starts focusing on, which I think is great and it seems to have worked out well for you.

Linda Mongero: Yeah, no it’s been great, it’s been great. Now I’m learning a whole nother facet of the industry, which is corporate perfusion, which I was never involved with and I really enjoy it.

Todd Schlosser: Yeah. I was reading an article I believe that you wrote, it actually may have been a talk that you gave that had been kind of transcribed online, and it was talking about realtime monitoring for perfusionist’s and how that was sort of changing the outcomes for the better, clearly. Can you talk a little bit about when realtime monitoring became sort of the standard, or is it now the standard, or is it not yet?

Linda Mongero: It isn’t quite the standard yet, but it is something that most perfusionist’s are getting engaged in, in their hospitals, because we’re not able to do electronic medical record keeping. Every hospital is required by the government by 2014 I think it was, Obama said it had to be done, but electronic doesn’t mean realtime electronic, it just means you can scan your document into the patients medical record. I was a little worried about it and I kept focusing on it when I was at Columbia, and I kept saying. “We have to go electronic, we have to go electronic.” Every year for budget I would go in and say, “Here’s what I want.” They’d say, “Okay, sorry Linda, there’s no money this year.”

Then finally, somebody donated a lot of money to the hospital and my administrator said, “I know you’ve wanted this for a long time, so this is what we’re going to do.” We actually got a realtime electronic medical record that was in realtime, that you were able to record every single thing, add all the other monitors that we monitor during perfusion in cardiac surgery, and develop this whole record that we could go back now and look and see what happened at the exact moment. A lot of people are afraid of that, because they’re like, “No, we don’t everybody to know what’s happening, what we’re doing.”
Todd Schlosser: But, there’s so much you can learn from that.

Linda Mongero: Absolutely.

Todd Schlosser: Yeah.

Linda Mongero: That’s what we did, and that paper that we wrote was looking at perfusionist’s that were able to see alerts during a case versus ones that had no alerts. Actually, the ones that had alerts performed 10 times better, just by virtue of the fact that you scan and you look at things and you monitor what you’re doing, but it’s seconds that you’re saving when something pops up and said, “This is out of line.” That was what that whole paper was about, and it was a presentation that I gave at a national meeting and yeah, it was really good stuff. It’s only getting better and better.

Todd Schlosser: Yeah, I’m sure as electronic health records become sort of standardized, but also people build databases too and make those searchable, that’s where it really becomes valuable.

Linda Mongero: It is.

Todd Schlosser: Let me ask you, your field of focus right now is sort of shifting. As you mentioned you kind of came out of the clinical space into the corporate space, and you’re over ECMO and ECLS. Can you talk a little bit about what ECMO, the extra corporeal muscular oxygenation?

Linda Mongero: Sure, yeah.

Todd Schlosser: Is that, I want to make sure I’m saying it right because it’s new for me.

Linda Mongero: Extra corporeal membrane oxygenation.

Todd Schlosser: Membrane?

Linda Mongero: Yeah, so an oxygenator is an artificial device that provides oxygen.

Todd Schlosser: Yeah, it pretty much does what the lungs do for your blood, yeah.

Linda Mongero: Exactly, and then the pump provides what the heart does-

Todd Schlosser: The circulation.

Linda Mongero: … that’s why we call it the heart lung machine. Classically-

Todd Schlosser: Is an ECMO machine the same?

Linda Mongero: Well, extra corporeal circulation is done in cardiac surgery, and the reason it has to be done is because they have to stop the heart. But, in ECMO, what happens is the lungs may be damaged, or the heart also could be damaged as well or just slightly impaired and can get better. Now, we’re able to put patients on long term support, extra corporeal support, it’s long term and it’s closed circuit. Just two cannulas, the pump, and the oxygenator. It got very-

Todd Schlosser: That’s much smaller than a regular, yeah.

Linda Mongero: It is, it is. It got popular around 2007, 2008, when a membrane oxygenator came out that had a special coating that allowed for patients to stay on long term support. Before that we really didn’t have, we had one oxygenator that did that. With that, at the same time in 2009 there was a influenza epidemic called the H1N1 virus.

Todd Schlosser: I remember that, yeah.

Linda Mongero: A lot of patients were, their lungs were failing, they got the flu they’re in the hospital, people were like, “What do we do with them?” But, hospitals that had the ability to go on ECMO, which my hospital did, we were already to go, to launch this method of saving lives. What was interesting was they did well. Then, all of a sudden from 2000, around 2000 I would say nine, 10, through 2013, 14, ECMO surged about 433%.

Todd Schlosser: So, a little bit.

Linda Mongero: It grew so big.

Todd Schlosser: It’s having a bit of a moment.

Linda Mongero: SpecialtyCare was like many hospitals around the country, you know, you do a few ECMO a year and some places did more. Pediatric and neo-NATAL ECMO has been around for 50 years.

Todd Schlosser: Oh, has it?

Linda Mongero: It has, and so we didn’t do well with adults because as I said we didn’t have that longterm support with an oxygenator. Now we do, and so now adult respiratory therapy is really taking off. It’s ARDS, it’s acute respiratory distress syndrome, and for various reasons, but the patients their lungs have taken a hit, they need to be rested. You put them on ECMO and you can rest the lungs and balance it, you have usually a pulmonologist or an intensivist that helps out. The perfusionist provides the equipment and we’re having really good success. We’ll do this year 850, company wide.

Todd Schlosser: Wow. Okay, so that’s quite an increase over what’s been in the past, even 10 years ago.

Linda Mongero: Absolutely.

Todd Schlosser: It’s been around for 50 years and it’s just now having it’s moment, in the adult space I should say.

Linda Mongero: Yeah, well in the last 10 years it’s really been seriously investigated, there’s tons of research that’s being done on it, but it’s still in it’s infancy really. But, worldwide, there’s a lot of respiratory therapy, respiratory distress I should say, and if we have the ability to do ECMO in more places we’re going to save a lot more lives.

Todd Schlosser: Okay.

Linda Mongero: Yeah.

Todd Schlosser: You said a few things that I just want to get some clarification on if it’s all right, so you said it’s sort of longterm support, whereas a regular heart lung machine run by a perfusionist is more just for like while you’re in surgery, correct?

Linda Mongero: That’s right.

Todd Schlosser: When you say longterm how longterm is that, not four to six hours, but.

Linda Mongero: Average seven to 10 days.

Todd Schlosser: Oh, that’s a lot longer.

Linda Mongero: That’s a lot longer. Seven to 10 days. Some two months, three months, four months.

Todd Schlosser: Wow, okay.

Linda Mongero: They’re putting patients on for bridge to transplants, and so they stay on this device.

Todd Schlosser: Wow, so people who are on like the heart transplant list can survive for months without a heart?

Linda Mongero: Correct, and lung transplant … no, their hearts still there, they disconnect them, but we help to manage the circulation.

Todd Schlosser: Okay, so is your heart still pumping while you’re on ECMO?

Linda Mongero: Yes, yes, it is.

Todd Schlosser: Oh okay, okay, so it’s not like when you’re in surgery for perfusion and your heart is stopped.

Linda Mongero: No, it’s not stopped, yeah.

Todd Schlosser: Okay, I was going to say that’s got to be the weirdest feeling ever.

Linda Mongero: Yeah, it is. Well, the weirdest feeling is when we used to do ECMO years ago the patients were, that was like a last resort. They were on their beds and they were intubated and they didn’t talk. Now, fast forward 10 years, they’re extubated, they’re sitting up in bed, they’re on a device but they’re talking to you. I mean, one of my first patients, I was in my pump room in the OR and somebody called on the phone, I picked it up, she said, “Hi, could you come over and tell some people please about this machine that I’m on.” I’m like, “Okay, sure, one sec, I’ll be right over.”

I walked over and it was the patient that was calling me. I was really, I was shocked, and I was like, “Oh.” She goes, “Could you just tell my friends about this machine?” I said, “Yeah, absolutely.” I was like, “Oh my god.”

Todd Schlosser: In fact I can tell them all about it, it’s what I do.

Linda Mongero: I was just amazed, and so it’s really good, it’s a really good thing.

Todd Schlosser: You may have already answered this a little bit but I want to get more clarification on it, and I want to talk about sort of standardization of ECMO if that is a fair question, or a fair way of saying it. But, how does a regular heart lung machine that is done in surgery, how do those differ from regular ECMO machines. Aside from just the miniaturization of them, which let’s talk about that in a bit too, but what are the differences between those machines?

Linda Mongero: The regular heart lung machine has, it does a few extra things. In other words, the patients chest is opened up so shed blood gets into that chest cavity, and that has to be sucked back to the heart lung machine. It gets back to a reservoir, it gets filtered, and then it, you know, it keep recirculating [inaudible] self.

Todd Schlosser: It’s like an auto transfusion machine does.

Linda Mongero: Yeah, similar to that, and that’s the patient, so it’s very open and invasiveness, okay, and so it’s bigger because it needs more than one pump. But ECMO only really needs one pump, so one thing to drive the blood either into the venovenous position where you take blood from a vein, oxygenate it, give it back to a vein. Then it goes, because the hearts working it travels through the heart and out to the lungs and let’s the lungs rest, and then oxygenates them as well and the total body. Then, you can also have VA ECMO, which goes back to an artery from a vein to an artery oxygenated, and that pump is helping to propel the blood around the circulation because the heart for some reason is failing a little bit or has, you know it’s inflamed. Various reasons why the heart, myocarditis, different reasons why the heart isn’t perfusing as it should, so it just might need some time to come back.

That is only two cannulas versus this invasive cardiopulmonary bypass full blown in the OR. But, it’s the same equipment. The oxygenators can be the same, but they have specialized oxygenators for ECMO as I said that are coated and they can be used for longterm support. When you do a VA ECMO and you’re in an operating room sometimes you’ll convert from being on bypass because the patient can’t ween to an ECMO situation, or it can just be we’re going on ECMO and that’s usually for like ARDS or maybe a bridge to transplant. Something that they anticipate that they may be on for a longer period of time.

Todd Schlosser: Okay. Obviously a perfusionist runs a heart and lung machine.

Linda Mongero: Correct.

Todd Schlosser: An ECMO longterm support up to seven to 10 days or months if need be, who is monitoring machine, or who is …

Linda Mongero: Because ECMO has grown so differently across the country, in my mind I’m a perfusionist. The front line manager or the go-to person for let’s go on ECMO is the perfusionist.

Todd Schlosser: Okay.

Linda Mongero: Okay. Now, that being said, we do have a perfusionist shortage right now in the country, and perfusionist’s not only are doing their cases, they can also do ECMO, but they can’t stay up 24/7.

Todd Schlosser: No, they can’t do a four to six hour case and then monitor someone for 12 hours.

Linda Mongero: Exactly, so what we’ve done is in some institutions they said, “Well, let’s have respiratory therapy help us out, let’s have the nurses help us out, or just get more perfusionist’s.” At New York Presbyterian when I was there what we did was use this realtime monitoring, we put a monitor by each patients bedside, and we used telemetry. The perfusionist’s watched the ECMO, and so it’s very involved. ECMO is a team sport, not one person can do it you need a whole team of individuals, and right now there are many respiratory therapists that are doing ECMO, a lot of nurses and nurses that are ECMO coordinators, and also perfusionist’s stay involved. But, for me because perfusionist’s do extra corporeal circulation, that’s our thing.

Todd Schlosser: That’s their wheelhouse.

Linda Mongero: Exactly, we’re the go-to, and most institutions that I’ve been in always have perfusionist backup if they don’t have the perfusionist running the ECMO.

Todd Schlosser: Okay, going forward is anyone looking to standardize that process?

Linda Mongero: There’s a national organization known as ELSO, Extracorporeal Life Support that has, it’s a registry. It’s been really, I think they started it in, I’d have to look that up for you but I’m going to say early in ECMO career with babies and then pediatrics. They are trying desperately to get organized to have a national certification process, so that’s, they’re working on that, it hasn’t happened and you can imagine after 50 years. We all do it very similarly, it’s not that different, it’s just every institution has it’s own protocols. Training is one of the most important aspects in that if you haven’t done it in a while that you get retrained, or that you have continuing education around ECMO.

Todd Schlosser: Right. I’d like to close on one final question I ask a lot of the people who have worked in perfusion related fields who are still perfusionist’s. We had a chief perfusionist in here like yesterday we were talking to and I asked him the same question. Because there is a perfusionist shortage, if you were talking to someone who maybe just graduated with a bio science degree, or maybe they’ve been a nurse for a few years and want to take a next step into furthering a career, what would be your sales pitch quote-un-quote to join perfusion as an industry?

Linda Mongero: I just think that the perfusionist is such a key personnel in the operating room and outside of the operating room. They learn to troubleshoot, that’s what they do, and a lot of times when things happen in the operating room if something goes wrong the perfusionist kind of comes to the rescue because they can figure things out very quickly on the run, we’re just trained to do that. If you like being in that kind of an environment, because it can be stressful-

Todd Schlosser: It can be.

Linda Mongero: … but it’s a fascinating field, and if we don’t knock ourselves out by being so short right now and we continue to get perfusionist’s to get into the field, there’s going to be all kinds of new things that perfusionist’s are going to be able to be involved in. Going out for heart transplant, there’s going to be gene therapy. There’s going to be things that are going to be extracorporeal, and the perfusionist already knows how to do this. It’s going to be a fascinating future. Now, that being said, all three of my children I said, “You need to be a perfusionist, you need to get into perfusion.” “Oh no, are you kidding, no way, we’re not going to do, call on all the things that you’ve done.” So, none of them are in this field, but there are plenty of kids that are interested in doing it and it’s really a fun profession. I’ve enjoyed it, I really have my whole life, and I just continually learn and I just love it.

Todd Schlosser: Well, I can’t think of a better place to stop. Linda Mongero, thank you so much for being on Scrubbing In, we really appreciate your time.

Linda Mongero: Thank you for having me.

Todd Schlosser: Absolutely, thank you so much.

Linda Mongero: Okay.

Todd Schlosser: Awesome.

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