Skip to main content
BY ELIZABETH ARMSTRONG MOORE
On the second floor of Legacy Emanuel Medical Center in Portland's Eliot neighborhood sits an odd machine.
It's 5 feet tall, with gleaming metal and long, green hoses. It looks like a scuba tank mounted on an airliner's beverage-service cart. The hospital won't disclose the price, but it probably cost about $105,000.
And if you're dying from the flu, this machine could well be your last hope.
What the machine does is called extracorporeal membrane oxygenation, or ECMO. It's essentially an external lung, and it's one of the last procedures available to people whose lungs are too damaged to heal on their own.
At this moment, Legacy Emanuel is the only hospital in Oregon with an ECMO center for adults. For decades, there were only a handful of these machines on the West Coast.
It is so valuable and effective that it travels, by ambulance and plane, to the far ends of the state, saving the lives of people whose lungs are shutting down.
Legacy's ECMO machine isn't used very often—but the No. 1 reason it's used on adults is a last-ditch effort to save them from the flu.
Since 2009—the year a particularly deadly flu strain debuted in Oregon—Legacy has used ECMO on 32 flu patients. Eighteen of them survived.
"The vast majority of flu patients do not need ECMO," says Dr. Sandra Wanek, a critical care surgeon who for the past two years has run Legacy's ECMO program. "It's not the bread and butter of what I do. But when it's necessary, there's nothing to replace it."
ECMO is a marvel of technology that provides a shield of last resort during flu season—a season that typically begins in December and can last until Memorial Day. The illness costs this country, by government estimates, $87 billion each year in heath care expenses and lost work days.
But ECMO also offers a small window into something else: how the skyrocketing costs of health care are often a result not just of, say, Big Pharma overcharging for drugs, but also the unwillingness of large numbers of people to put prevention ahead of treatment.
Consider this: If every Oregonian got a flu shot, which is covered by all insurers, very few if any people would need an ECMO machine to treat the lung failure that comes from severe cases of flu.
But because 56 percent of Oregonians choose not to get a flu shot, the ECMO machine is occasionally wheeled in to treat the most virulent cases.
The cost of using ECMO? Roughly $150,000 per patient.
"Getting a flu vaccine can save millions of dollars down the line," says state Sen. Alan Bates (D-Medford), a family osteopath. "Not getting the vaccine? Worst-case scenario is you die, or you end up in the hospital with an incredibly expensive procedure. It all could be prevented by a $20, $30 shot."
It was a Wednesday night when Joe Favela felt the fever set in.
The 41-year-old Newberg construction worker didn't think much of it. He rarely got sick.
But on this night in February 2014, Favela had a few things working against him: He was overweight, he had been a smoker for 30 years who only recently quit, and he never got the flu shot.
By Sunday morning, Favela realized something was very wrong.
"I felt like I'd been hit with a Mack truck," he now recalls. "My whole body was in intense pain. My whole body was hot. I was sluggish. And I had terrible headaches."
Most alarmingly, he found himself gasping for air.
Favela decided to go to Providence Newberg Medical Center, but he was already slipping in and out of consciousness.
He doesn't remember stepping into the driver's seat of his pickup truck; his mother, Manuela Favela, was in the passenger's seat, begging him to pull over as he weaved across blacktop lanes on the cold, gray morning. They argued and somehow made it to the hospital.
Within 15 minutes of admitting Joe Favela, doctors told Manuela Favela that her son was at death's door. He'd come in with double pneumonia and full-blown H1N1 influenza. Not only were both his lungs failing, his lone kidney and liver were also shutting down, putting considerable strain on his heart.
"They told me there was nothing they could do for him," Manuela says now. "Then 15 minutes later, they said Legacy Emanuel in Portland had a machine, and that's all I heard—one machine, and they could take him."
Joe Favela's hold on life was too tenuous to survive the long ambulance ride to Legacy Emanuel, so the hospital's team brought the machine to him.
He lived—thanks, his doctors say, to ECMO.
His only outward sign of being an ECMO survivor is the tracheotomy scar on his throat. It serves as a visible annual reminder—get a flu shot. After all, he says, "You can't ever, never put a price on life."
You can, however, trace the choices that Legacy Emanuel made to have an expensive procedure that could save Favela.
The first time ECMO was used in Oregon, it wasn't for the flu.
Instead, it was in response to one of the worst disasters in state history: an Oregon Episcopal School climbing trip on Mount Hood.
A freak blizzard swept in on May 12, 1986, when the climbers were just 100 feet shy of the summit, and it killed eight students and a teacher. Brinton Clark, who was 15, was put on ECMO.
Clark's heart rate was 30 beats per minute, her blood pressure barely detectable, and her core temperature an astonishing 73.4 degrees. But within 13 minutes on Legacy Emanuel's new machine, the teen's pulse began to normalize.
She was the first adult saved by ECMO at Emanuel—thanks to Dr. Jonathan Hill, a cardiothoracic surgeon who brought the equipment to Legacy one year earlier.
In ECMO, invented in the 1970s in California, Hill found a machine that could allow injured lungs to rest long enough to give the body a chance to start healing.
When a person's lungs or heart are failing, ECMO uses a mechanical pump to pull blood from a central vein out of the body and into a circuit. The machine adds oxygen, removes carbon dioxide, and warms or cools the blood as needed before pumping it back into the body. (See chart on page 16.)
When used as a temporary lung bypass, ECMO is often described as "lung rest": A machine does the work of the lungs so the real ones have a chance to recover on their own.
In the 20 years after using the machine on Clark, who is now a doctor at Providence Medical Group, the hospital used ECMO on some 125 adults, averaging roughly five patients a year.
"I'm the guy who gets to walk into the hospital in Medford and sees someone who is going to be flat-out dead," Hill says. "And I'm the guy who is going to send her or him home, and back to a family. And that's the best part of this."
For years, Hill worked on what critics considered the fringes of mainstream medicine.
The use of ECMO on adult patients was once seen as radical, and has been more widely used only since the flu pandemic of 2009.
That's because for decades, the data showed ECMO didn't work much better than simpler, conventional treatments.
Studies suggested that while "lung rest" helped premature infants, it didn't increase the chances of adult patients surviving the breakdown of their respiratory systems. For years, patients who were put on traditional ventilators or placed on their stomachs had nearly identical survival rates.
But the technology behind ECMO improved. The survival rate got better. And the flu got worse.
In April 2009, doctors spotted a particularly virulent case of influenza in a 10-year-old in California.
The strain was soon identified as H1N1. It would infect between 40 million and 80 million people in the United States, hospitalize a quarter million, and kill almost 16,000 by the end of the year.
ECMO, which doctors at Emanuel use to treat influenza more than any other illness among adults, has since become a popular weapon in the fight against the flu: Dozens of hospitals are buying machines, including Oregon Health & Science University.
"We get phone calls from all over," says Wanek, who arrived at Emanuel in 2013. "ECMO now is sexy. Everybody wants to do ECMO."
Emanuel handles more ECMO patients than ever—after averaging five a year for decades, the numbers jumped to 25 adult patients in 2013, 35 in 2014, and 27 thus far in 2015, with several weeks of flu season looming.
And Emanuel's survival rate? Since Wanek's arrival, it's reached 56 percent for flu patients, and 84 percent overall.
Still, despite the increased success rate, 14 of the 32 flu patients placed on ECMO in the past six years died. (All but one of those 32 patients had skipped a flu shot.) And even those who survive go through lengthy hospital stays, and don't always see their health return to the same level as before they got sick.
And that's to say nothing of the monetary costs of this care. Legacy won't divulge financial data, but reports in medical journals state that the costs of ECMO care range between $100,000 and $213,000 per patient, though cases can top $1 million.
That's because ECMO treatment is extremely resource-intensive. Emanuel staffs three nurses for every ECMO patient—around the clock.
Wanek resigned from Legacy Emanuel last month.
"I just can't handle another flu season," says the Army Reserve surgeon and mother of two young boys who is about to deploy to Afghanistan.
"This is preventable," Wanek says. "Flu shots are free. And this is a horrible way to die."
Getting a flu shot doesn't mean you won't get the flu: The Centers for Disease Control and Prevention estimate it was as low as 14 percent effective last year (depending on the strain and patient population).
Yet experts agree: Flu deaths are almost totally preventable through the vaccine, even when it's a poor match to the dominant or most lethal strains circulating, because it still provides antibodies that may not eliminate the virus's effect but will diminish it.
The U.S. health system is filled with examples of expensive care, some of which could have been prevented.
Dialysis and other treatments for failing kidneys cost Medicare $30 billion a year, according to the U.S. Renal Data System. Lung-cancer costs reach $12 billion a year—much of it avoidable if people quit smoking. And obesity? The CDC says care for the morbidly overweight costs $147 billion annually.
But perhaps none of those health decisions is as stark as the $10.4 billion spent each year treating the flu—including the costs of ECMO.
Many people don't think of the flu as deadly—or they imagine it killing only the very old, the very young or the very weak. But, in fact, recent strains of the flu tend to be the most dangerous to otherwise healthy adults.
Yet Oregon's vaccination rate remains about the national average: 44 percent. Some of those who don't get flu shots are vaccination skeptics, who argue that flu shots are both ineffective and dangerous.
Dr. Paul Thomas, a Southwest Portland pediatrician who has argued against mandating vaccinations, says he's not opposed to the flu shot—but worries that multi-dose vials contain mercury..
"The flu shot is notoriously one of the least effective of our vaccines," Thomas says. "If you take the flu shot in a pregnant woman, this is a dangerous proposition because we're not looking at long-term what this does. What's the flu shot doing to one's overall health?"
Dr. David Zonies, a surgeon developing an ECMO center at OHSU, calls fears about mercury in flu shots "insanity" and says the science disproves any concerns.
Most of the people who don't get vaccinated, however, skip the shot for more mundane reasons: They're busy, or they figure it won't do any good.
"Science literacy is at a very low level right now," says state Rep. Mitch Greenlick (D-Portland), who chairs the Oregon House Health Care Committee. "We have whooping cough back now, we have measles back, because people are refusing to do things that make sense. The point is, people should get flu shots."
Disclosure: Elizabeth Armstrong Moore, who reported this story, is married to a nurse in the Legacy hospital system.
Flu by the Numbers
6: Number of people hospitalized with the flu in the Portland metro area so far this season.
795: Number of people hospitalized with the flu in the Portland metro area during the 2014-15 season.
1%: Percentage of Oregon emergency-room visits for flu-like symptoms for the week of Nov. 22-28.
36%: Estimated percentage of Multnomah County residents who have gotten a flu shot this season.
44.3%: Percentage of Oregonians 6 months or older who got a flu shot during the 2014-15 season.
47.1%: Percentage of Americans 6 months or older who got a flu shot during the 2014-15 season.
17 million: Estimated workdays lost by Americans to the flu each season.
$10.4 billion: Estimated direct expense of flu treatment nationwide each year.
3,000 to 49,000: The range of annual deaths from the flu from 1976 through 2007. (The Centers for Disease Control will only provide a broad range of annual deaths, saying that flu season varies in length and severity each year.)
Sources: U.S. Centers for Disease Control and Prevention, U.S. National Institutes of Health, Oregon Health Authority.
Willamette Week