Hi I’m Kathleen Schultz I’m a clinical engineer at Aurora Saint Luke’s Medical Center I’ve been working there for 10 years with the ventricular assist device program And I’m here today to tell you a little bit about our devices and how you may interact with them out in our community When we talk about a left ventricular assist device, we’re talking about a device that is going to take over some of the function of their left ventricle It works in parallel with their native heart So we don’t remove their heart We basically core a little piece of their left ventricle out and put in one of our devices Then the blood that goes into their left ventricle is then pumped through our device back into the aorta, and pumped back into the rest of their body It does take over the majority of the function of their left ventricle, but not all of it They still will get some blood going from their left ventricle into the aorta through the aortic valve itself At Saint Luke’s, we currently use two different types of non-pulsatile LVADs We use the HeartMate II and the HeartWare device Both of these devices are able to have the patient go home on them When we talk about devices and why we use them, there’s a couple reasons There’s one called the Bridge-to-Transplant With a Bridge-to-Transplant patient, these patients ultimately will be transplanted at the end of their device life We are basically putting in a device to make them healthy for when they go into transplant because we want them to be like you and I We want them to be able to walk as much as they can We want them to be able to exercise So it’s basically to build their endurance back up We also use Bridge-to-Transplant devices in our very large type “O” patients Type “O” blood type patients are a little harder to transplant So they’re on that transplant list a little longer Unfortunately, the length of the list also causes them to often become sick or in their heart failure So we’re able to put these devices in, and we’re able to give them a better life until their transplant comes Now, kind of the way the whole bad world and transplant world is going is that most patients who will get a transplant will be on a LVAD before transplant It’s just how it’s going We’ve noticed that the healthier we can take them into the transplant, the better off they are with their transplant, and their transplant surgeries go a little better So at Saint Luke’s, probably about 75% of our patients who go to transplant have an LVAD prior to it And again, they can be discharged home The other indication that we’re starting to use now, and it’s been approved in the last probably about 10 years, is destination therapy Destination therapy patients are not transplant candidates There’s many reasons why they may not be transplant candidates It could be their age At Saint Luke’s, we have a soft cut-off of 70 We do do some patients over 70 if they are very physically active patients, but most of the time our cut-off for transplant is 70 We also– if they have a lot of health conditions– we may not be able to transplant them right now whether they have renal failure, whether they have cancer, other things that may cause them to not currently be able to be on the transplant list Well, we don’t want to promise those type of patients a transplant if we can’t give it to them So what we do them is we say– oh, we can still put this pump and is destination therapy, but we’re asking them to bear with us and see if we can fix their health condition And then when their health condition is fixed or becomes at a point where they can be transplanted, then we move them back over to the bridge to transplant list Compliance is another huge issue We are advocates for the donor family We are not advocates for our patients So we want to make sure that our patients are a hundred percent compliant, and that they’re going to treat their new organ with the respect that it deserves So if we have any sort of judgmental issues with our patients on their ability to be compliant with medications, alcohol, or drug use, things like that, we may actually say– you know what, you have to prove to us you’re going to be compliant, and then we will give you a heart So we basically do a social contract with them and say these are the things that you have to do, and when you fulfill that social contract we then will move you back over to Bridge-to-Transplant The other reason that we may put it in for destination therapy is obesity If somebody is over a BMI of 40, which is basically a ratio between their height and their weight, if it’s over 40 we can’t transplant them It’s too hard to find them a healthy organ So then we say to them– you know what, we will put this device in you, and we will give you the ability to go out and exercise, we’ll educate you on what you need to eat, and you need to come back to us and show us that you’re going to lose the weight you need in order to get that transplant

We also are one of the only programs in the nation who actually also has a good relationship with gastric bypass So a lot of our patients, if they’re really obese and they’re showing us that they’re doing what they need to do, we actually will refer them to our bariatric program to get a lap band, or usually only a lap band because it causes issues later with transplant if they have a full gastric bypass, but we do have a program with that All of the patients who are destination therapy, they’re at high risk of intervention, high risk of death if we don’t intervene soon Usually the protocol is if we don’t do something and put a device in them, their life expectancy is about six months is what we’re looking at These patients will live on this device They are never promised a transplant They’re given basically contracts and say– if you follow these, we will go ahead and possibly move you over to that transplant list, but you really have to prove it to us So when they’re put in, we do give them a palliative care consult, because we know that they could die on this device that might be there end-all They could eventually again move to that transplant list if things get fixed, and then they can be discharged home on these devices to live on them Currently, at Saint Luke’s we are about a 50/50 in our Bridge-to-Transplant and our destination therapy list Now when we talk about these new types of devices, before we get into them I want to just talk about what non-pulsatile devices are When I first started at Saint Luke’s, our devices were about the size of a paint can lid, and they were about two inches thick So imagine putting that in a patient That was pretty big It was all motorized and it would break in about a year and a half So the companies and the health care world said– you guys have to do something about this So in order to make them smaller, we had to make them what we call non-pulsatile So basically when we talk about non-pulsatile, our devices have no valves in them So they have no ability to close and shut It’s just one opening that goes through With that the easiest way to picture it is like water coming out of a garden hose We call it continuous flow So whatever the device gets the device is going to spit out When it comes out of the end of our device, or what we call our outlet, it is also going to have no pulsatility to it It is, seriously, like water out of a garden hose So with that in mind, our patients will have very, very low blood pressures, and their difference between their systolic and their diastolic pressure is pretty small We’re looking at about a 5 to 15 millimeter of mercury due And that difference, and that– what we call pulse pressure, the difference between the systolic and diastolic– is literally just on their own heart and their contracting So that’s what causes that difference, but again we minimize it So there is no usually blood pressure of 120 over 80 We’re looking at 90 over 70, 80 over 60, sometimes We’re looking at much lower blood pressures They’re typically not palpable at the extremities So even though it may have a little bit of pulse pressure when it leaves our device and hits the aorta, by the time it gets out to their arms and their legs, if you try to feel pulses they’re often diminished, or gone So it does cause a little bit of problem for people who meet them in the community because they’re used to feeling a pulse, and our patients often don’t have that The patients still do need their native heart We did not take it out We attach these devices to their native heart, and for our devices to work and work effectively, we really that need that native heart to still pump So we’re really dependent on still that contractility that that native heart has always had And we will try to correct the heart if it’s not functioning right because our device will see and have problems with that Similarities among all of our LVADs that we use, even the ones that I’m not going to show you today– we do have some at the hospital that maybe don’t go home or are a different kind that we rarely use, but all of our devices will have what we call a driveline And this is basically a line that exits their body usually on the right side, and this is what delivers all the power to the device and actually allows the device to communicate back with us This driveline is very, very important that we keep and maintain it We don’t want any cuts in it We don’t want any breaks it because if we break things we break the wires, we break the communication, or we break the ability to provide power to it All of our devices will have a controller, basically the brains of the system It’s like a little mini computer It’s all programmed It’s what provides– tells the pump what to do, and it also is what reads what the pump is doing and gives you visual and audible alarms if anything is wrong It has two batteries They will all have a battery charger, and they will all have some sort of AC power unit for sleeping Basically all that is is a unit that plugs up into the wall and provides the patient continuous power so that when they’re sleeping they don’t

have to worry about running out of battery power What we do at Saint Luke’s, though, is we encourage our patients only to use that wall unit when they are sleeping We did not have them go through this big surgery that requires a full chest opening for them to sit on a power unit and not get out and exercise So we tell them when you get up in the morning, you need to get on batteries, and you need to stay on batteries all day so that you can go ahead and be living life, and going to the store, and going out to eat, and going to be with your family and friends Again, the types of LVADs that we’re going to talk about today are our two most common types It’s the HeartMate II device and the HeartWare device When it comes to which one we choose, it really comes down to a couple things Usually the physician will choose based on the patient’s size, their heart failure, sometimes it depends on if it’s in a clinical study or not If it is in a clinical study, sometimes a patient may not qualify so they may be forced to the other one If the physician really has no reason to choose one device over the other device, we actually show both to the patient We show them what they’re going to take home, how they’re going to have to live, give them a small synopsis of how it functions, and we let the patient choose what they feel will fit into their lifestyle the best When we talk about the HeartMateII, this is currently the most common LVAD that we do use at Aurora St. Lukes There is a picture on the screen with it, but here is the LVAD also What happens is it does take over pumping for the left side of the heart This is what we call an inflow right here So when I talked earlier about coring out that left ventricle, basically it’s almost like an apple core We just go in there and we take out a small piece of the ventricle in which this inlet can fit in We basically then pop this into the inlet All of this pump stays down just below their ribcage inside of them And this is our outflow in which we go ahead and we sew right back to the aorta So we’re taking the blood from the left ventricle that it normally would have used We spin it through our pump, which is this gray portion right here, and we put it right back where it should have gone, the aorta Again, this is the driveline We’ve talked about this a couple times, this white cord So basically this is going to tunnel underneath them, come out on the right side of their body And this is what you will see, basically, is just this cording piece of material from here to here It’s going to come out so this patient only has this much distance in order to move This pump itself is projected to last about five to ten years There is truly no contacting parts inside of here So there really should be nothing that wears or tears inside of it and breaks, but just in the time of being on And what we have to do is we have to do something called anticoagulate these patients because we put a foreign body inside of their body Their body likes to reject it a little bit So what we have to do is these patients will be on coumadin and aspirin in most cases, and usually that fluctuation in coumadin and aspirin at some point in time may cause this pump to clot off So that’s where we get that projected five to ten years is more how easy they are to what we call anticoagulate When they’re on coumadin, there is a level that we can watch to see what their level is at And that’s called an INR We look for an INR of 1 1/2 to 2 1/2 for the HeartMate II With that in mind, that is not any higher than a patient who is out there on atrial fib, or has a valve, arm surgery or replacement So we’re really not asking for a hugely increased INR than other common heart surgeries out there With the HeartMate II, some patients can be off of anti-coagulation if they have a history of a GI bleed What happens with the devices is sometimes they will have an increased risk of GI bleeding So the HeartMate II does allow our patients to take it off of them, off of coumadin for that history of GI bleeds We already talked about where it exits the body So, again just above the waistline With this driveline, this white piece that will come out of here, will then attach to something called a controller This is the controller Off of the controller is two other lead So this driveline right here will go into the controller right here, and then off of there comes two power leads in which they would have to have batteries or a power unit attached at all times This is our older controllers So we actually have two different controllers currently out in the community and on our HeartMate II patients The older controller looks like this It provides power to the LVADs still like before, still controls everything

It does provide visual and audible alarms through this panel on the front here And when the patient leaves they will always have an extra controller with them So in this case, if they have this controller, the driveline is actually going to attach right here So this white line would come in right here and attach, and then their batteries are coming off on one on each side The controller actually has been upgraded to a new controller which is the first one I had out here The nice thing about this controller is it not only gives you symbols, but it actually gives you words So it’ll tell you how to fix it or what’s going on So there’s not a lot of guess work with this newer controller The batteries– the patient will wear two batteries at all times So this controller right here is actually attached to a driveline and running so it has two batteries attached to it at all times For a battery to interface with the controller, it does require a clip So you just put these two together, and go on and put it on to the pump It does require that two power sources be attached to it at all times So it either has to have two batteries, or it’ll have the power module cable which has two ends to it that are attached Once a patient on HeartMate II goes on to a set of batteries, a set of batteries is going to last them about 12 to 15 hours So they will actually get the majority of their day out of one set of batteries Unless they sleep two hours a night, they really are going to get all day on one set of batteries You’ll see on this slide there’s also a picture of a power module That’s what they would use to provide AC power The thing with the HeartMate II is this box is about a foot by a foot It has to sit in one room It’s about 10 to 15 pounds So the patients don’t like to move it around So it’s often going to be found in their bedroom So if you do ever go to their house and you’re looking for their power module, we tell them to put it where they’re going to sleep because that’s where they’re going to need it So it is often found in a bedroom The next slide shows the Universal Battery Charger So again, obviously these batteries need to be recharged at some point in time So the patient goes home with eight batteries Their battery charger charges four at a time So they are taught to rotate through all eight of their batteries at any given time When the batteries are not hooked up into the charge, if they’re just sitting there not being used, they will hold a charge for well over a month So they should be able to rotate through them pretty easily If the patient has the older controller, the manila-colored controller, they will also on top of their power module have a display module That is what gives them all of their numbers It gives them all of their alarms in verbal or in written form So they have that portion to it with that display module With the newer controller that’s all available right there for you at that time because the display module only works when you hook up to the power module So it wasn’t quite as convenient as the new controller The Heartware devices, the other one that we commonly use So this is the Heartware device This device is currently approved for just Bridge-to-Transplant It is in a study for destination therapy It’s not a study based on how effective the pump is It is more based on a study on what blood pressure you need to maintain to make this pump not clot off for long periods of time Because again, remember, that destination therapy patients are going to live on this device So they really are looking at what is that blood pressure? Again, it works very similar to before We still have an inflow It sits at the top of this pump, still requires a full chest opening The nice thing about this one is it does sit right at the apex of their heart So not below their ribcage, but rather behind their ribcage So if we have a shorter, smaller person, this device sometimes fits in a little better because it doesn’t have to go down into their abdomen at all I do not have the graph material on this pump, but it has the same kind of grafting material that comes off of here and goes right back to the aorta Again, this pump is projected to last about five to 10 years, just like the other pump The only thing is this one does require a tiny bit higher INR We’re looking at two to three for this device And they’re pretty strict on that two to three They don’t like us to take people off of anti-coagulation if they’re bleeding with this device At times we have no choice but to do that, but we try to leave it on Again, the picture here shows how it fits in there

It shows the pump right at the base of the heart It shows the driveline– mine’s a little twisted– coming out on the right hand side And then this driveline, again, attaches to a controller box And then this controller box has to attach to some sort of power source When we talk about accessories, again, this is their controller The big selling point on this one used to be that it had the LCD screen, but now HeartMate II has come to the new century and has also given them an LCD screen It still does the same thing the HeartMateII does It still provides all the power to the pump It also takes information for the pump and gives it back to the user So this is what is going to provide them any of their visual or audible alarms, based on if something is wrong with the pump There is a picture of how it is carried in a bag down below on the PowerPoint And they still are required to carry an extra one of these around when they leave the house So basically, any patient who leaves their house should always have an extra controller with them, no matter which device they’re on, and they should have extra batteries with them A battery for this device is the small gray box right here I’m going to pick up this whole thing And it plugs into the controller just like this These are a little nicer They’re just a turn and a push to get them in It can operate, or it does operate on just one battery at a time So even though you are required to have two power sources attached to your controller at all times, it is only draining one of them at a time So with that in mind, the batteries do only last about four to six hours, and then the patient will get a little beep that tells them that they need to put a new battery on that side Once they replace the battery, then the beep goes away The controller will automatically switch to the other power source that’s attached to it so the patient doesn’t have to run out of power It just is notified every four to six hours that they have a volt battery The nice thing about this, which I didn’t bring here, is this device does have an AC– what they call power cord It’s a lot like a laptop brick so that core that runs to your laptop, that’s what their AC cord is So rather than that one by one foot box, it’s really a portable cord with them So these patients, even though their batteries may not last as long, [INAUDIBLE] is very portable So we actually do encourage these patients, if they’re just sitting around watching TV, why run on your batteries? Just plug into the wall because the cord is really easy and portable to move around We also encourage them if they’re going out of their house to take one of their AC cords with them They do go home with two to have it with them so that they can hook up when they’re just sitting around doing nothing They also are provided with a DC adapter, which is something that the HeartMate II does not have So these patients, if they’re one of those that’s going to travel– we actually have a patient that is currently on his way to Wyoming in a car– and he is using his DC adapter It plugs into its power cord in his car, and he can hook up and run off of his car battery while he’s driving to Wyoming And he doesn’t have to worry about– worrying about his batteries changing because this patient physically himself is driving to Wyoming He is the one driving So we don’t want him to have to worry about running out of power as he’s driving About probably 50% of our patients drive We do allow them to drive There’s nothing currently in the state of Wisconsin that stops them from driving So they are restricted to about 12 weeks after surgery before we allow them to drive This device also has a battery charger just like the other device It charges four batteries at a time It allows them to– so if they have four to six hours out of their battery, it’s going to take them about four hours to recharge that battery This device does go home with only six batteries, but, remember they do have that AC cord that they’re allowed to use during the day a little more freely So they don’t eat through quite as many batteries When we talk about complications– so now we put this in, we say they’re OK to leave the hospital and we send them out to the community What complications are you guys maybe going to see with these patients? One of the main complications that we have are arrhythmias On There’s right heart failure There’s low volume Device malfunction Bleeding Infection And thrombus and stroke When it comes to arrhythmias, remember before I told you that our pump is really dependent on that heart functioning as it’s intended Because that’s what fills our pump When your heart contracts, it pushes blood through our pump a little faster So we need that heart to work

Remember too, earlier, I told you that this only supports the left side of their heart Well, there’s a whole other side of the heart called the right side And the right side is what feeds all the blood to the lungs, oxygenates that blood, and then that blood comes from the lungs into your left side And then that’s that oxygenated blood that your tissue in your body get when your left side pumps it out Well if we leave these patients in arrhythmias for long periods of time, we’re going to put out that right side of the heart and it’s not going to function as it was intended And then our device isn’t going to function as well And then guess what happens? Your end organs, your livers, your kidneys, all of those type of things, they don’t get profusion They don’t get oxygenated blood So we can’t leave our patients in arrhythmias for long periods of time With that in tow, our patients will tolerate an arrhythmia So you may walk up upon one of our patients and they may be in v-tach or v-fib Well, guess what? They’ll be talking to you So it’s a little strange because that’s not normally what you see out there When people especially are in v-fib, they’re down on the ground You’re doing CPR usually And our patients, sometimes will talk to you They may tell you they don’t feel the best, but they’re likely not going to hit the ground and pass out in most cases They’ll be talking We still want you to get them out of them So if their AICD hasn’t gone off on its own, we want you to externally defibrillate these patients Again, if the right size is not working and it can’t get blood through the lungs and it can’t get it to our left side, then our pump can’t function So we really have to work on that right heart failure With that in mind, out in the community, do not underestimate the amount of patients that we may have on some sort of Viagra in some way, shape, or form may come in different names, Revatio or Magellan But ask even our female patients– are you on some sort of Viagra before you treat these patients because they often are That is one of the medications that we commonly use to help that right heart function It helps lower those pressures and the lungs for us so that right side doesn’t have to work quite as hard So low volume, that is another thing that we’re going to deal with here We did not cure their heart failure Again, there’s no cure truly for heart failure All we’re doing is finding a way to assist their heart failure so it’s not quite as overcoming to them So with low volume, what happens sometimes is we sold these patients on diuretics And we’re limiting their intake, and we’re giving them diuretics such as Lasix, furosemide, things like that So we always are bouncing back and forth on that low volume issue So you may run across a patient who has low volume The other thing that comes with low volume, and we’re going to jump ahead a little bit, is that bleeding So if that patient is doing some GI bleeding, or bleeding somewhere else or they’ve been bleeding profusely out of their nose which happens sometimes, they may become a low volume state And we have to supplement that low volume state Because what happens if we don’t stop that low volume state– remember, I told you all of these inflows are sitting in their left ventricle– if we don’t have enough volume in that left ventricle, our ventricle sucks down around that inflow And if our inflow taps that ventricle wall at all, it often will cause that patient to go into v-tach or v-fib So we really are juggling that low volume state Device malfunctions I know it sounds horrible, but they actually are pretty rare The devices are actually pretty reliable They may get a battery here or there that goes wrong, but when we’re looking at device malfunctions they often are just a change of a controller In most of the time, the patient can come to us and we can change their controller It’s still functioning, just something maybe isn’t working a hundred percent right with it So often they’re not even changing their controllers at home They’re coming to us When we talk about device malfunction, the big one really is, jumping ahead again a little bit, is that thrombus and stroke issue Because if we start building any sort of issue up inside our pump, it can’t spin like it wants to And it starts to cause some heart failure issues with these patients So when we’re thinking that there may be some sort of thrombus in our pump, we start looking for things like Coca-Cola color urine So if you come across our patients and they have really dark urine, when we get them to the hospital we start looking at things like their labs There’s a value called LDH that we check There’s a value called plasma for hemoglobin If all of those are elevated, along with that Coca-Cola colored urine, plus there’s a number on the device called power that we watch, if that’s also increased those are all really indicated that the patient may have some sort of thrombus building up inside of them They also always risk that stroke Just because we put a foreign body inside of them they always will have a risk of stroke, and that ability to build up some sort of clot and basically spit it out of our pump, and then it goes to their head or to some sort of arm or limb With that in mind, there is also infection

I know I talked about it last, but this is probably the number one problem our patients have Remember I told you earlier, we have that exit site that’s coming out of the right side Well, that’s basically a foreign body coming out of their thing If they tug or pull on that exit site, it’s going to open it up Well, as soon as you open it up, guess what? Those little bugs like to get in there Once our patients are infected, if they have a full-blown infection and they don’t call us early, it will often remain infected for the duration of their pump life They often will end up on antibiotics for the duration of their pump life which often becomes a miserable life for them So we really encourage our patients to be mindful of that exit site We actually have them wear a device a little further down from their exit site So if they drop their bag or something like that, which is going to happen at times, it pulls on that device and not the actual exit site itself to avoid infections When we talk about the EMS ED role, or just the community role in general, we do want you guys calling us and asking us if you have any questions So anytime you come across a patient who may be having a problem out in the community, we do ask that you guys use the numbers that are on the controllers On the HeartWare controller, the numbers are going to be on the back of the controller And on the HeartMate II, the numbers will also be on the back of the controller for you Those numbers will give you the EMS, or it will give you all the pager numbers for the engineers It also gives you the surgeons and the transplant clinics’ numbers So you have full access to us at all times When the patient does go home, we do notify their immediate community that they are out there So if the patient lives in Milwaukee, we notify the Milwaukee EMS If the patient lives in Racine, we notify the Racine EMS So if the patient lives in Waukesha, we’ll notify Waukesha’s EMS But remember these patients aren’t homebound They don’t have to stay home Remember earlier, I said we have a patient going to Wyoming right now So we then also notified Wyoming So if they travel, we ask that they let us know that they’re traveling so we can set them up with the safest way to travel in centers out and about But again, a patient from Waukesha could very easily go to Pleasant Prairie to go shopping, and a Racine person could run across them out in the communities So again, it is important to remember that if you need them at all that those numbers are on the back of the controller So if the patient can’t communicate with you, you need to look for those numbers and communicate with us so that we can help you out in the community about getting them back to us Again, the patients and the families are completely trained on these devices When they leave our hospital, they know exactly how to run them, how to troubleshoot them, how to change controllers, how to notice if things are going wrong It is not the community’s responsibility to know how to troubleshoot them What we like to do is come out and educate you guys so you guys can see what they are, what a battery is, what a controller is So when you get out there, if the patient is stumbling through things, you’ve seen it already We do ask, though, that if you do come across them and they need to be put in an ambulance and taken to a facility that you do allow a device-trained individual to go with them, especially if the patient is in some sort of distress, because they may not be able to one hundred percent operate their own device at that point in time We also ask that you try to get a hold of the engineers and let us know that you’re coming in so that we can meet you in the ER because if it’s the weekends or nights, we’re not at the hospital So we’re coming from home We also ask that you really help us make sure that the patient leaves the house with the back-up controller and extra batteries I know sometimes that’s the hardest thing to do when the patient’s in distress, you just want to get them in the rig and get them out, but we really need that extra controller when they hit our hospital So they may need assistance carrying that equipment We do encourage our patients to try to keep their extra controller and an extra set of batteries in a bag ready to go at all times So often if you just ask them– where’s your emergency bag, where’s your back-up controller They’ll know right away like- oh, it’s right by the door, or, it’s right here Sometimes it’s just a little bit of communicating with them because they’re often forgetful when they’re in that distressed state If the patient is medically stable, we do asks that you try to take them to St. Luke’s We do understand if they’re not within the Milwaukee area sometimes that’s a little hard to do So you can take them to a local hospital That local hospital then would hopefully communicate with us, or if you can remind them to communicate with us with the numbers on the back of the controller that they’re out there, and then we will communicate with them on what is the best course of action for that patient It’s becoming more common that LVADs are out there

So now you’re seeing that a lot of times our patients will go to outlying and ERs, and they’ll actually get treated and get discharged home from those outlying ERs It’s not always necessary that they come to St. Luke’s as much as it used to be If the patient is clinically unstable, though, we really need them to go to the closest hospital because we don’t want anybody to miss a treatment because you took a three hour drive from Green Bay down to Milwaukee So at that point in time, we have no choice but to take them to the local hospital and get them stabilized, and then get them transported down to us Now what is the EMS ED role when it comes to LVAD– so if you’re not a LVAD trained person, what are you supposed to do with these patients? Well, we do understand that assessing these patients is very hard because remember, again, this is a non-pulsatile left ventricular assist device So we took away every measurement that you guys are used to using We took away their blood pressure in most cases We took away their pulse in most cases So you really have to go back to things that are clinical signs You need to look– are they breathing? Are they warm? Do they have capillary refill? Push their finger down and see how fast it takes their fingernail to fill back up If they’re talking to you, even if they don’t have a pulse, please don’t do anything crazy with them Just call us, and we’ll help you through it So with that in mind, with blood pressures, that’s always the big question for us What do we do with that blood pressure? Because, guess what? It’s not always going to be picked up by an automated cuff which people are used to using You can try it We do run our devices a little slower than we used to to help with that GI bleed problem, just to keep a little more pulsatility in these patients So sometimes that automatic blood pressure cuff will work If you do get it to work, fine, you can take that number But again, remember, that number may not be what you’re used to looking at When it comes through that automated cuff, it may only be 80 over 60 I don’t want you pumping a bunch of volume into my patient because that’s normally what people would do at that point in time If you have an 80 over 60, we are looking for a mean pressure between 60 and 90 for these devices So we don’t treat a systolic and diastolic with these patients We treat a mean So again, you may have some patients out there with lower blood pressures If you put too much volume in these patients, you’re going to push them into congestive heart failure So again, we walk that really thin line If you cannot get that automated blood pressure cuff to work, sometimes it requires that you use a Doppler And what you would do is you would put a normal manual cuff on their arm You’re going to blow it up You’re going to put the Doppler where you would listen And when you hear that first swoosh sound, guess what? That’s the number you’re going to take You will not hear a second number You’re just going to hear that first swoosh number And we want that number somewhere to be 60 and 90 We consider that kind of like their systolic mean So again, if you can’t get it to automatically read, then you will have to find a Doppler and use a Doppler pressure Now what happens if your patient application comes in and they’re not stable? They’re not able to talk to you They come in They’re basically full-blown coating Well, guess what? We made it easy for you Follow all your ACLS protocol You still want to attach EKG rhythms to these patients That’s one of the biggest things we see out in the community is patients who have LVADs, people don’t want to do the normal Guess what? You’re AICDs will work Your AEDs will work You want to get ECG cables on there Make sure that they’re not an arrhythmia, that that’s not what’s causing their problems If they do you have an arrhythmia, we want you to shock them out of it Again, remember though, that a lot of them will be awake and alert and oriented So if you’re going to shock them externally, please sedate them first because they won’t be very happy with you If you have to do chest compressions on these patients– let’s say that they have no pulse You can’t find it They’re not talking to you They’re starting to turn gray They’re starting to turn cold Guess what? You have no choice Do chest compressions To us at St Luke’s, we have the little saying– dead is dead So please, try to save them and do the chest compressions If you do nothing, they’re going to die So we can’t stress more than anything, look at that rhythm If you only have an AED– if they go down at church, and you have an AED, pop it on them It’ll work We want to keep them out of those arrhythmias And again, follow all the ACLS protocol The only thing I caution again is make sure that the patient’s not on some sort of Viagra In general, LVAD troubleshooting So again, we don’t train you, but everybody wants to know– what do we do? How do we do this?

What do we do if we come across this patient and their controller’s alarming? Well, guess what? In general, if the controller is not alarming and you come across one of our patients, they have at least 2 1/2 liters of flow going through them Our devices, both devices, alarm if their flow is less than 2 1/2 liters So with that in mind, you’re not going to get much more with that with doing chest compressions So unless that patient is truly turning gray and cold, I wouldn’t jump into them if the controller’s not alarming If the controller is alarming, we do ask that you verify that the power source is attached So if this is the hardware, you want to make sure the batteries are attached to it And then the HeartMate II, you want to make sure the batteries are attached to the power leads In both cases, these pumps will not run if batteries are not attached So you may come across a patient that has just accidentally disconnected both of his powers So if there is not power attached, please attach power If there is still good power attached, and the thing is still alarming, we want you to verify that the controller’s detached to the driveline So in this case, on the heartware, it’s making sure that the silver connection is in the actual controller and hasn’t come out The HeartMate II, depending on which controller you have, it’s either going to go into the top here, or if you run across some of our older patients that are out, it’s going to be on the side here So it’s just making sure that that controller has not come out at all from the driveline Because if the controller’s not attached, there’s no way to provide power to the pump So the pump will stop again If it’s still alarming, at that point and time you need to page one of the engineers at the 414-222-7434 number, and we’ll help you do any additional troubleshooting that you would need to do out in the field With that in mind, I will remind you there has been times where the EMS or the ED has had to call us and they’ve had to put a battery on, or they’ve had to find equipment for us And this is why we do these talks, so that when I’m on the phone with you and I say– can you find a battery? You know what a battery looks like I’d like to thank you now for assisting us in helping us get these patients back out to the community and living their lives again For us., it’s huge in their recovery process