Letter to the Editor Brian Burns, Ambulance Service of NSW 25 October 2011 Letter to the Editor Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Dear Editor, I congratulate Dr. Ciapetti et al. for their recently published article in the Journal. (1). It is difficult to make robust conclusions from such a small case series, but this paper does highlight two important points. Firstly, ECMO retrieval can be done safely where there is a well-organised system with appropriately trained medical personnel with large experience in retrieval medicine and ECMO. Secondly, the authors reported 2 episodes of hypoxia (SpO2 less than 90%) in the conventionally transported group. The CESAR trial highlighted the dangers of transporting such patients by conventional ventilation. In that study 3 died prior to transport and 2 died in transport by conventional means. (2) Patients with severe ARDS should often be deemed unsafe for transport without ECMO, particularly where long journeys are envisaged, as in our jurisdiction. Lastly, the authors stated that ¿little has been written on transport while on ECMO for ARDS in adults; it has been described only in one case report for ARDS-related H1N1¿. This is not the case. We have published on the logistics and safety of ECMO retrieval on 17 patients during the H1N1 pandemic (3) and also on our experience of ECMO retrieval since the ECMO program (4) was established in New South Wales, Australia¿s most populous state. In the latter study, we retrieved 40 patients on ECMO of whom 16 were confirmed or suspected H1N1. These patients had comparable Murray scores (median 3.75[3.5-3.75]) to Dr. Ciapetti¿s cohort over a median distance of 250km. Overall survival to hospital discharge was 85%. We believe that retrieval of patients on ECMO will increase in the future as this lifesaving therapy is brought out of the specialised ECMO centre and to the patient¿s side, wherever that may be. Yours sincerely, Dr Brian Burns, Dr. Karel Habig, Dr. Cliff Reid Greater Sydney Area HEMS, Ambulance Service of NSW, Australia. References 1. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu (H1N1)-related ARDS. Marco Ciapetti, Giovanni Cianchi, Giovanni Zagli et al, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:32 2. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Peek GJ, Mugford M,Tiruvoipati R et al. Lancet 2009 374:1351-1363 3. Logistics and safety of extracorporeal membrane oxygenation in medical retrieval. Burns BJ, Habig K, Reid C et al. Prehosp Emerg Care. 2011 Apr-Jun;15(2):246-53. Epub 2011 Feb 4. 4. Retrieval of critically ill adults using extracorporeal membrane oxygenation: an Australian experience. Intensive Care Med. 2011 May;37(5):824-30. Epub 2011 Feb 26. Forrest P, Ratchford J, Burns B et al. Competing interests No conflicts of interest to declare.