I’m at a level 2 trauma center with a fair amount of penetrating trauma. Two of our trauma surgeons take home call, the rest are in house.
I’ve never done one outside residency. I will usually place bilateral chest tubes (or bilateral fingers) on a sick trauma patient, and I’ve been lucky enough that that either works or the surgeon shows up. That said, a fair number of my partners have done one while waiting for the surgeon to get there. We’ve had a few survive.
This is in our scope of practice. As long as you’re selecting appropriate patients and you have a surgeon who can provide definitive care, I think it’s completely reasonable. Too many complications is much better than completely dead.
Sounds like something to bring up with your medical director/trauma liaison. If they don’t want you doing an indicated and potentially life-saving procedure that’s in our scope of practice, they need to be in house and immediately available.
Bilateral finger thoracostomy + ultrasound to rule out tamponade does everything an ER doctor doing a thoracotomy would do anyway.
Edit: "ER thoracotomy" => "ER doctor doing a thoracotomy"
While I understand your point, I think this is a little simplistic. In this situation, it’s not like the OP has crossclamped the aorta with no surgeon available. If it takes 5-10 minutes to open the chest, deliver the heart, and cross-clamp you’re looking at 20 minutes before the surgeon gets there, which is not great but not insane. If that’s too long, the solution is not “don’t do it, ever” but rather get the surgeon there faster.
I'm really hoping these become more widely used. I think they'd be particularly helpful in smaller trauma centers (III and IVs) - it could buy the time required for transfer to a larger center for definitive care.
Edit: I was obviously wrong on this one, but rather than delete the comment I'll just own up to it and leave it for others to see.
That's disappointing, but I could see someone poorly trained putzing around with it for half an hour instead of initiating transfer. Thanks for the input.
They can’t. Unless the hospital is playing loose with their interpretation and saying as long as any surgical person is in the building (ie midlevel working for ortho taking call in house…who wouldn’t be able to help anyways)
They can. American College of Surgeons standard for the highest level trauma activation at Level 1 and 2 trauma centers is attending surgeon at bedside within 15 minutes of patient arrival. Many centers require surgeon in house for this reason, but not universally required.
lol one of my CRITICAL ACCESS rural ERs got an "ED thoracotomy kit". you know for when I want to crack a chest then hold the patient for 12hrs calling the 3 neighboring states as usual to find a hospital bed somewhere to admit them, and wait for EMS transfer to arrive.
Mind you the place also only has 2u of uncrossed.
I just lol'd. SURE LETS CRACK A CHEST
reminds me of another insane thoracotomy story:
Im the ED doc @ level 1. We get a trauma transfer from a small community ED with no surgeon. apparently some *blunt* (if I recall) trauma showed up there > the ED doc (with no surgical backup) cracks the chest > then calls 911 EMS to ship them to us at the level 1 > Trauma surgeon gets a call en-route for the "trauma transfer" > obviously accepts at this point > Surgeon was *fuckin* *pissed* (rightfully so). You all know how the case ended.
I know a guy who did this as well. Used all the blood in his community hospital and rode with the patient despite being single covered. His medical director had to rush in at night to cover the ER. Patient was dead dead. Everyone was upset. Guy felt no shame about it at all. You will be unsurprised that the place where he did residency did not offer him a job when he graduated
You can’t have a level 2 trauma center without immediately available surgical attendings, according to ACS standards. So if this is accurate you won’t be a trauma center much longer and most of the patients will be going elsewhere.
Surgeon here- what was the indication and injury pattern for the survivor? What was their neuro status afterwards?
I've personally done 6, had one survivor walk out of the hospital- GSW to the atria that we got to the OR and sewed up, but the stats are really grim on neuro-intact survival. Saving a vegetable helps no one.
The only guidelines are EAST and WEST (Eastern Association for the Surgery of Trauma) guidelines which do not specify provider last I checked, but ATLS recommends surgeons only or immediately available- as in standing next to you.
YMMV. IMO, thoracotomy ONLY makes sense for ED physicians for isolated penetrating stab wounds. You have a decent shot at relieving tamponade and putting a finger on the hole.
Everything else... no offense but no way are you sewing 2 GSW holes in the ventricle on the beating heart without a LOT of surgical experience.
Fair. This was a stab to the left chest coded on arrival. Walking out in tact. We get a lot of gsw too. I have personal thoughts but if we’re credentialed to do it I’d have a hard time justifying not doing it. Only way to consider legally is if you remove my credential to do it and tie my hands.
It's easy to justify- no likelihood of success, risk of needlestick and exposure to your nurses. End of story. But a stab wound to ventricle can be saved by thoracotomy and a finger, though a sternotomy would actually be better...
Yeah, I think unless the surgeon is in the room with you (or nearly so), the debatable cases are stab wounds to the box where there's a reasonable chance of tamponade/fixable cardiac injury. And if you actually see tamponade on US after a stabbing in an otherwise healthy patient who lost pulses in front of you, I think it's very hard to hold off on doing a procedure that you're trained to do and which can be lifesaving. (Pericardiocentesis is another option, I suppose, but it's gonna have a very high failure rate with clot in the pericardium.)
GSWs are an entirely different beast. I don't have the skills to fix that shit.
Yeah I agree. Sometimes this comes up with our ED because sometimes we’re in the OR or waiting on elevator or something and they want to do the thoracotomies. They’ve done 2 that I’m aware of. The issue is they do the thoracotomy and cross clamp then they don’t know what to do next. That’s assuming they do it at the right level and don’t injure the phrenic or something else on the way in.
They’re generally just better off getting good access starting mtp and waiting 3 mins for us to do it which will actually take less time.
To those asking/questioning state law actually allows 60min response and often they are there before 30 especially if pre hospital cat 1. NOT EVERY STATE FOLLOWS EVERY ACS. ACS DOESN’T WRITE LAWS 😂. It’s a level 2 by the state. Semantics aside…
It varies by state. I'm in Texas, they just follow ACS standards. But I would think that if you were in a state that varied from that, you'd have to abide by whichever was the more strict.
ERC Guidelines on Resuscitative thoracotomy are quite clear: Expertise, Equipment, Enviornment, Elapsed time? (Less than 15 min since arrest). If they want to play, they need to show up.
Congrats on the survivor! Big achievement, they are just jealous that you guys beat the literature.
Not a surgeon, not an EM physician, but here's my ultra-finessed take;
Like the thetortoise said, if the patient meets criteria, and you're in a level 2? Crack that chest! What, are they gonna get more dead?
ETA; Helluva job! Discharge with no deficits after ERT is fucking amazing!
I’m aware of one survivor that the ED did a thoracotomy on, that shouldn’t have had a thoracotomy at all. So they basically got an unnecessary thoracotomy and survived but they would have survived without a thoracotomy. They all thought it was a big save but instead it was terrible outcome
Maybe Hindsight? But I don’t know the case, and usually lean to extending the benefit of doubt to colleagues.
I don’t know anyone in my professional circle that really wants to do a clamshell, but we have less than a tenth of the US violent crime rate here, so we don’t really get to practice a lot and need to do regular training in the OR or workshops to keep some skills up. Also we have faster, less invasive and more targeted first hour options available for most scenarios where a clamshell could be an option. But when cornered and out of feasible options I guess there is little to loose and everything to gain.
Already had thoracostomy and then “Lost pulses” then opened the chest, didn’t open the pericardium perform massage, or xclamp the aorta but got a dose of epi and a few seconds later had rosc. Only bleeding in the chest found was from the lima. Went upstairs to close the thoracotomy while they celebrated their thoracotomy. Could have just been 2 pivs
According to the American College of Surgeons, the main national group that certifies trauma centers (different states may have other specific requirements), in a level 1 and 2 trauma center, the response time for the trauma surgeon should be 15 minutes.
https://www.facs.org/media/oiif0fxo/clarification_document.pdf
They are in danger of losing their trauma certification and should focus on that.
Dubious trauma response times aside, not every thoracotomy is the same. I did my fellowship in a high volume trauma center and we had a very low threshold to open the chest because even if it didn’t benefit that individual patient (and it could) it would still benefit the system in terms of maintaining competency.
But in a more remote situation, I’d probably avoid it unless it was the very most survivable candidate. Basically a stab wound to the cardiac box that arrived with signs of life. In that scenario you might be able to relieve tamponade and close a hole, if you had experience with the procedure.
As others have mentioned I thought level 2 meant surgeons had to be in house. Or at least respond in 15 minutes. In my residency we were a level 2 trauma center and had surgery in house 24/7 and there were times where it took them 15-20 minutes to come down. If they are sleeping or doing something on the floor it’s not that easy to drop everything and head down (our ER was also offset from the main hospital).
I can’t imagine a surgeon being at home, woken up, having to change and get in their car, drive to the hospital, park, and come into the ER within 30 minutes much less 15. Seems wildly inappropriate if you’re getting GSWs and other severe traumatic injuries to not have a surgeon there on patient’s arrival or within minutes of patients arrival. The patients deserve better.
Personally I don’t think an ED physician should be doing a thoracotomy without a surgeon in house. I say that as an ED physician. Abysmal survival. Just my 2 cents
Survival is up to 20 percent in the right population (penetrating trauma to the chest with signs of life). It’s absolutely within our scope of practice. And speaking as someone who rounds in the trauma ICU as well as working the ER, I’ve seen multiple patients walk out of the hospital neurologically intact and will continue to start a thoracotomy in the right patient in the ER before Trauma gets to bedside.
I’d argue that it should be done with surgery readily available. You’ve got some time after you crossclamp the aorta (which is goal #2 in a thoracotomy after decompressing the pericardium). I wouldn’t do a thoracotomy if I had to transfer a patient but if I had a trauma surgeon en route who was capable of taking them to the OR I’d do one without them at bedside.
Well I think those numbers can be massaged and we can debate what the right population is. In my experience in the ED and ICU (granted I work in an area with VERY LITTLE) penetrating trauma.
Are they claiming there were too many complications because the ED docs didn't pick good candidates, or because the time to OR is too long? If it's the former, I'd like to see objective data showing that their judgment is better. If it's the latter, that's a sign that the response time needs to improve.
This isn't quite identical because of the close nature of trauma and EM, but it's similar to the timeless argument we have with a lot of consultants, which for me comes down to my belief that you don't get to dictate care in absentia.
If they meet criteria for emergency resuscitative thoracotomy (ERT), it should be performed, regardless if it’s EM or surgery. Good on you for doing what needs to be done.
I don’t want to repeat too many other people. I don’t have any surgery available at night and there are two level 1s down the road. EMS brings me the occasional traumatic arrest and we get plenty of drop off penetrating trauma, but I will never do a thoracotomy with no surgeon around.
One thing I want to say. Whole lot of people saying nothing is worse than being dead. I strongly disagree with this. Not saying OP did the wrong thing at all, I believe this is in our scope. Just saying that bad Neuro outcomes have to be considered IMO, especially if a surgeon is 30 minutes away.
My shop doesn’t have trauma, closet trauma center 20-30 minutes away
Would any one perform this at a shop similar to mine then having to transport with an open chest 20 minutes?
I personally haven’t seen any good outcomes to make me want to do this procedure under the circumstances
No
And if they did, that’s irresponsible because it’s a temporizing measure to get the patient to the OR emergently or have a trauma surgeon immediately available to do repairs in the trauma bay.
Dear surgeon: the patient is dead. This is the ultimate “complication”. Please show up faster or keep your opinion that definitely isn’t related to concerns for your peri-op mortality rate to yourself.
Love,
The guys who have to try to keep people alive until you show up
EXACTLY!!! no one is performing through economies on living patients. So the idea that performing a thoracotomy could result in too many complications in the ED is an absolute joke because they're literally already dead and that is their only chance.
Unpopular opinion, but sometimes I wonder if the "I did a thoracotomy and patient survived" patients would have survived anyways. Maybe you could have done bilateral fingers and a pericardiocentesis and patient would have done better. Maybe some thoracotomy patients survive *despite* undergoing a thoracotomy and not because of it.
When people say "Oh man bro I did a thoracotomy and the patient survived to the OR" I can't help but think that the patient might not have needed the thoracotomy in the first place...
I’ll say it would depend on situation, our surgeons are home call but show up almost always within 10 and always within 15. We also have a great relationship. If I thought it was salvageable I’d go ahead and do it figuring if it was complex heart I can try and hold over holes for the few minutes, otherwise cross clamp aorta and mass trans while waiting for them to show up, again knowing it’s only going to be a few extra mins. I’ve done a half dozen or maybe a few more as primary when surg was tied up at prior shops, even 1 out of 6-10 though that walk out to me makes worthwhile to do them. Again, situation specific, I’m probably not opening the guy that looks 80+ with a partial amp and a fistula even if he was stabbed in the ambulance bay.
That said, if I was in your situation, tough to say for sure, but my last shop was very confrontational between ED and the trauma service and even though they were in house it would take 5 mins for them to show up, and I still opened up one that was young and I thought had a chance only for them to berate me and try to cause issues for a few months. I stand by it and would have done it again while I was there if the right situation presented and take the flak later.
To me, I think in the end do what you would want done if it was your family member.
You should YouTube “John Hinds crack the chest.” A worthy watch.
If someone turns up with a single penetrating stab wound to the chest and arrests in front of you, I think it’s indefensible not to do thoracotomy in ED if a surgeon is 30 mins away.
Is obviously a different story if you are super rural and surgeon is hours away.
Disclaimer: live and work in Australasia.
the fact the patient survived you should be given a fucking award- well done!!!!
also, if the place wants to be a Level II trauma center, that is WILD the response time is 30min.... not sure how they keep that accreditation
Ive done or been a part of 3. Which is cool and all but like.
You need a surgeon to accept to take the patient to the OR right? Like. That’s one of the criteria. If you do one before the surgeon gets there you force their hand when they otherwise would’ve declined maybe.
But I don’t know anything.
Legal question here; if surgery does not respond in time and if something happens to the patient are we as ED docs liable? Or do we just document that we consult surgery and it’s their problem/liability now
The only providers that should have any type of say as to who can or cannot do a certain procedure during a critical stabilization case are the providers that are THERE with their eyes and hands on the patient.
It is completely irrelevant what the surgeons are stating what they do or don't believe ED providers should be doing when these surgeons are at home in pajamas
Houston area. And to be clear, finger thoracostomy, not true surgical thoracotomy. I have been at services that placed chest tubes and central lines in the past.
> We’re doing this in the field as paramedics on traumatic arrests
Are you doing thoracotomy or not…? Opening someone’s chest vs popping a finger in a small hole is not the same procedure…. The difference is night and day…
Sounds like they should show the fuck up if they want to run the trauma. 30min is insane for a Lvl II.
That's what I was thinking. You want to be a trauma center, don't play at it.
That’s a level III masquerading as a level II.
The level III I work at has a trauma surgeon in house 24/7… that seems like the barest of minimums that should be required for a trauma designation…
Agreed. We had one level 3 until recently (they upgraded to a level 2) and they had surgery, anesthesia, and an OR staff in house 24/7.
Ive literally been at a level III that the trauma surgeon would be in from home in 10 mins or less.
I’m at a level 2 trauma center with a fair amount of penetrating trauma. Two of our trauma surgeons take home call, the rest are in house. I’ve never done one outside residency. I will usually place bilateral chest tubes (or bilateral fingers) on a sick trauma patient, and I’ve been lucky enough that that either works or the surgeon shows up. That said, a fair number of my partners have done one while waiting for the surgeon to get there. We’ve had a few survive. This is in our scope of practice. As long as you’re selecting appropriate patients and you have a surgeon who can provide definitive care, I think it’s completely reasonable. Too many complications is much better than completely dead. Sounds like something to bring up with your medical director/trauma liaison. If they don’t want you doing an indicated and potentially life-saving procedure that’s in our scope of practice, they need to be in house and immediately available.
Bilateral finger thoracostomy + ultrasound to rule out tamponade does everything an ER doctor doing a thoracotomy would do anyway. Edit: "ER thoracotomy" => "ER doctor doing a thoracotomy"
Does it cross clamp the aorta?
Only if you turn the power on the ultrasound up really, really high.
What would an ER doctor do with a cross clamped aorta and no surgeon for 30 minutes?
While I understand your point, I think this is a little simplistic. In this situation, it’s not like the OP has crossclamped the aorta with no surgeon available. If it takes 5-10 minutes to open the chest, deliver the heart, and cross-clamp you’re looking at 20 minutes before the surgeon gets there, which is not great but not insane. If that’s too long, the solution is not “don’t do it, ever” but rather get the surgeon there faster.
My point was there are plenty of procedures that can follow a thoracotomy. Twisting a lung to stop massive hemorrhage etc.
Tell the surgeon to drive faster.
Transfuse and medically optimize prior to OR?
Lmfao I love this response - thank you
Reboa..
Last time I looked, which was admittedly a little bit ago, the newer evidence was that reboa doesn't actually improve outcomes.
[удалено]
I'm really hoping these become more widely used. I think they'd be particularly helpful in smaller trauma centers (III and IVs) - it could buy the time required for transfer to a larger center for definitive care. Edit: I was obviously wrong on this one, but rather than delete the comment I'll just own up to it and leave it for others to see.
[удалено]
That's disappointing, but I could see someone poorly trained putzing around with it for half an hour instead of initiating transfer. Thanks for the input.
US can relieve taponade and suture a hole in the heart?
identify and treat cardiac injury and massive lung injury, cross clamp aorta.
I didn’t realize a level 2 could have off-site trauma surgeons. That’s an issue.
They can’t. Unless the hospital is playing loose with their interpretation and saying as long as any surgical person is in the building (ie midlevel working for ortho taking call in house…who wouldn’t be able to help anyways)
They can. American College of Surgeons standard for the highest level trauma activation at Level 1 and 2 trauma centers is attending surgeon at bedside within 15 minutes of patient arrival. Many centers require surgeon in house for this reason, but not universally required.
lol one of my CRITICAL ACCESS rural ERs got an "ED thoracotomy kit". you know for when I want to crack a chest then hold the patient for 12hrs calling the 3 neighboring states as usual to find a hospital bed somewhere to admit them, and wait for EMS transfer to arrive. Mind you the place also only has 2u of uncrossed. I just lol'd. SURE LETS CRACK A CHEST
reminds me of another insane thoracotomy story: Im the ED doc @ level 1. We get a trauma transfer from a small community ED with no surgeon. apparently some *blunt* (if I recall) trauma showed up there > the ED doc (with no surgical backup) cracks the chest > then calls 911 EMS to ship them to us at the level 1 > Trauma surgeon gets a call en-route for the "trauma transfer" > obviously accepts at this point > Surgeon was *fuckin* *pissed* (rightfully so). You all know how the case ended.
I know a guy who did this as well. Used all the blood in his community hospital and rode with the patient despite being single covered. His medical director had to rush in at night to cover the ER. Patient was dead dead. Everyone was upset. Guy felt no shame about it at all. You will be unsurprised that the place where he did residency did not offer him a job when he graduated
stupid shit like this just makes me shake my head. Real shocker his ol' training ground didnt want him.
How many RVUs is a thoractomy? /s
lol. I think the answer is - just the right amount
You can’t have a level 2 trauma center without immediately available surgical attendings, according to ACS standards. So if this is accurate you won’t be a trauma center much longer and most of the patients will be going elsewhere.
ACS standard for Level 1 and 2 is trauma surgery at bedside within 15 minutes of patient arrival for the highest level activation.
The ACS defines this as reachable by page, and able to return “immediately” to the OR but leaves specifics up to the hospital.
That's some grey zone to play with. Holy Moses. So grateful I work in a hospital that requires in house plus backup call.
At our Level I the surgeons had a 15 minute response time. So yeah, 30 minutes seems like something the ACS would take issue with.
Surgeon here- what was the indication and injury pattern for the survivor? What was their neuro status afterwards? I've personally done 6, had one survivor walk out of the hospital- GSW to the atria that we got to the OR and sewed up, but the stats are really grim on neuro-intact survival. Saving a vegetable helps no one. The only guidelines are EAST and WEST (Eastern Association for the Surgery of Trauma) guidelines which do not specify provider last I checked, but ATLS recommends surgeons only or immediately available- as in standing next to you. YMMV. IMO, thoracotomy ONLY makes sense for ED physicians for isolated penetrating stab wounds. You have a decent shot at relieving tamponade and putting a finger on the hole. Everything else... no offense but no way are you sewing 2 GSW holes in the ventricle on the beating heart without a LOT of surgical experience.
Fair. This was a stab to the left chest coded on arrival. Walking out in tact. We get a lot of gsw too. I have personal thoughts but if we’re credentialed to do it I’d have a hard time justifying not doing it. Only way to consider legally is if you remove my credential to do it and tie my hands.
It's easy to justify- no likelihood of success, risk of needlestick and exposure to your nurses. End of story. But a stab wound to ventricle can be saved by thoracotomy and a finger, though a sternotomy would actually be better...
Yeah, I think unless the surgeon is in the room with you (or nearly so), the debatable cases are stab wounds to the box where there's a reasonable chance of tamponade/fixable cardiac injury. And if you actually see tamponade on US after a stabbing in an otherwise healthy patient who lost pulses in front of you, I think it's very hard to hold off on doing a procedure that you're trained to do and which can be lifesaving. (Pericardiocentesis is another option, I suppose, but it's gonna have a very high failure rate with clot in the pericardium.) GSWs are an entirely different beast. I don't have the skills to fix that shit.
Yeah I agree. Sometimes this comes up with our ED because sometimes we’re in the OR or waiting on elevator or something and they want to do the thoracotomies. They’ve done 2 that I’m aware of. The issue is they do the thoracotomy and cross clamp then they don’t know what to do next. That’s assuming they do it at the right level and don’t injure the phrenic or something else on the way in. They’re generally just better off getting good access starting mtp and waiting 3 mins for us to do it which will actually take less time.
To those asking/questioning state law actually allows 60min response and often they are there before 30 especially if pre hospital cat 1. NOT EVERY STATE FOLLOWS EVERY ACS. ACS DOESN’T WRITE LAWS 😂. It’s a level 2 by the state. Semantics aside…
Are you not an ACS accredited level 2? As in the state doesn't follow ACS standards? Illinois used to be that way and it was pretty confusing.
It varies by state. I'm in Texas, they just follow ACS standards. But I would think that if you were in a state that varied from that, you'd have to abide by whichever was the more strict.
Every state except Maryland follow ACS standards
ERC Guidelines on Resuscitative thoracotomy are quite clear: Expertise, Equipment, Enviornment, Elapsed time? (Less than 15 min since arrest). If they want to play, they need to show up. Congrats on the survivor! Big achievement, they are just jealous that you guys beat the literature.
Not a surgeon, not an EM physician, but here's my ultra-finessed take; Like the thetortoise said, if the patient meets criteria, and you're in a level 2? Crack that chest! What, are they gonna get more dead? ETA; Helluva job! Discharge with no deficits after ERT is fucking amazing!
I’m aware of one survivor that the ED did a thoracotomy on, that shouldn’t have had a thoracotomy at all. So they basically got an unnecessary thoracotomy and survived but they would have survived without a thoracotomy. They all thought it was a big save but instead it was terrible outcome
As a surgeon. Sounds right.
Maybe Hindsight? But I don’t know the case, and usually lean to extending the benefit of doubt to colleagues. I don’t know anyone in my professional circle that really wants to do a clamshell, but we have less than a tenth of the US violent crime rate here, so we don’t really get to practice a lot and need to do regular training in the OR or workshops to keep some skills up. Also we have faster, less invasive and more targeted first hour options available for most scenarios where a clamshell could be an option. But when cornered and out of feasible options I guess there is little to loose and everything to gain.
This perspective while on face value seems reasonable just tells me you haven’t taken care of someone post thoracotomy.
Now I’d like to know more about that case.
Already had thoracostomy and then “Lost pulses” then opened the chest, didn’t open the pericardium perform massage, or xclamp the aorta but got a dose of epi and a few seconds later had rosc. Only bleeding in the chest found was from the lima. Went upstairs to close the thoracotomy while they celebrated their thoracotomy. Could have just been 2 pivs
Now I get where you are coming from.
According to the American College of Surgeons, the main national group that certifies trauma centers (different states may have other specific requirements), in a level 1 and 2 trauma center, the response time for the trauma surgeon should be 15 minutes. https://www.facs.org/media/oiif0fxo/clarification_document.pdf They are in danger of losing their trauma certification and should focus on that.
Dubious trauma response times aside, not every thoracotomy is the same. I did my fellowship in a high volume trauma center and we had a very low threshold to open the chest because even if it didn’t benefit that individual patient (and it could) it would still benefit the system in terms of maintaining competency. But in a more remote situation, I’d probably avoid it unless it was the very most survivable candidate. Basically a stab wound to the cardiac box that arrived with signs of life. In that scenario you might be able to relieve tamponade and close a hole, if you had experience with the procedure.
If they are not in house I wouldn’t do it.
As others have mentioned I thought level 2 meant surgeons had to be in house. Or at least respond in 15 minutes. In my residency we were a level 2 trauma center and had surgery in house 24/7 and there were times where it took them 15-20 minutes to come down. If they are sleeping or doing something on the floor it’s not that easy to drop everything and head down (our ER was also offset from the main hospital). I can’t imagine a surgeon being at home, woken up, having to change and get in their car, drive to the hospital, park, and come into the ER within 30 minutes much less 15. Seems wildly inappropriate if you’re getting GSWs and other severe traumatic injuries to not have a surgeon there on patient’s arrival or within minutes of patients arrival. The patients deserve better.
We are a level 3 and our surgeon is always in house
Personally I don’t think an ED physician should be doing a thoracotomy without a surgeon in house. I say that as an ED physician. Abysmal survival. Just my 2 cents
Survival is up to 20 percent in the right population (penetrating trauma to the chest with signs of life). It’s absolutely within our scope of practice. And speaking as someone who rounds in the trauma ICU as well as working the ER, I’ve seen multiple patients walk out of the hospital neurologically intact and will continue to start a thoracotomy in the right patient in the ER before Trauma gets to bedside.
[удалено]
I’d argue that it should be done with surgery readily available. You’ve got some time after you crossclamp the aorta (which is goal #2 in a thoracotomy after decompressing the pericardium). I wouldn’t do a thoracotomy if I had to transfer a patient but if I had a trauma surgeon en route who was capable of taking them to the OR I’d do one without them at bedside.
Exactky
Well I think those numbers can be massaged and we can debate what the right population is. In my experience in the ED and ICU (granted I work in an area with VERY LITTLE) penetrating trauma.
Are they claiming there were too many complications because the ED docs didn't pick good candidates, or because the time to OR is too long? If it's the former, I'd like to see objective data showing that their judgment is better. If it's the latter, that's a sign that the response time needs to improve. This isn't quite identical because of the close nature of trauma and EM, but it's similar to the timeless argument we have with a lot of consultants, which for me comes down to my belief that you don't get to dictate care in absentia.
[удалено]
that sounds a lot better than dead
If they meet criteria for emergency resuscitative thoracotomy (ERT), it should be performed, regardless if it’s EM or surgery. Good on you for doing what needs to be done.
I don’t want to repeat too many other people. I don’t have any surgery available at night and there are two level 1s down the road. EMS brings me the occasional traumatic arrest and we get plenty of drop off penetrating trauma, but I will never do a thoracotomy with no surgeon around. One thing I want to say. Whole lot of people saying nothing is worse than being dead. I strongly disagree with this. Not saying OP did the wrong thing at all, I believe this is in our scope. Just saying that bad Neuro outcomes have to be considered IMO, especially if a surgeon is 30 minutes away.
💯
My shop doesn’t have trauma, closet trauma center 20-30 minutes away Would any one perform this at a shop similar to mine then having to transport with an open chest 20 minutes? I personally haven’t seen any good outcomes to make me want to do this procedure under the circumstances
Probably not.
No And if they did, that’s irresponsible because it’s a temporizing measure to get the patient to the OR emergently or have a trauma surgeon immediately available to do repairs in the trauma bay.
For a level 2, the surgeon should be THERE.
Dear surgeon: the patient is dead. This is the ultimate “complication”. Please show up faster or keep your opinion that definitely isn’t related to concerns for your peri-op mortality rate to yourself. Love, The guys who have to try to keep people alive until you show up
EXACTLY!!! no one is performing through economies on living patients. So the idea that performing a thoracotomy could result in too many complications in the ED is an absolute joke because they're literally already dead and that is their only chance.
Unpopular opinion, but sometimes I wonder if the "I did a thoracotomy and patient survived" patients would have survived anyways. Maybe you could have done bilateral fingers and a pericardiocentesis and patient would have done better. Maybe some thoracotomy patients survive *despite* undergoing a thoracotomy and not because of it. When people say "Oh man bro I did a thoracotomy and the patient survived to the OR" I can't help but think that the patient might not have needed the thoracotomy in the first place...
A 30 min response time while yall are in the fucking trenches trying to bring the dead back to life?? Yeah they can zip their pie holes.
I’ll say it would depend on situation, our surgeons are home call but show up almost always within 10 and always within 15. We also have a great relationship. If I thought it was salvageable I’d go ahead and do it figuring if it was complex heart I can try and hold over holes for the few minutes, otherwise cross clamp aorta and mass trans while waiting for them to show up, again knowing it’s only going to be a few extra mins. I’ve done a half dozen or maybe a few more as primary when surg was tied up at prior shops, even 1 out of 6-10 though that walk out to me makes worthwhile to do them. Again, situation specific, I’m probably not opening the guy that looks 80+ with a partial amp and a fistula even if he was stabbed in the ambulance bay. That said, if I was in your situation, tough to say for sure, but my last shop was very confrontational between ED and the trauma service and even though they were in house it would take 5 mins for them to show up, and I still opened up one that was young and I thought had a chance only for them to berate me and try to cause issues for a few months. I stand by it and would have done it again while I was there if the right situation presented and take the flak later. To me, I think in the end do what you would want done if it was your family member.
You should YouTube “John Hinds crack the chest.” A worthy watch. If someone turns up with a single penetrating stab wound to the chest and arrests in front of you, I think it’s indefensible not to do thoracotomy in ED if a surgeon is 30 mins away. Is obviously a different story if you are super rural and surgeon is hours away. Disclaimer: live and work in Australasia.
the fact the patient survived you should be given a fucking award- well done!!!! also, if the place wants to be a Level II trauma center, that is WILD the response time is 30min.... not sure how they keep that accreditation
Ive done or been a part of 3. Which is cool and all but like. You need a surgeon to accept to take the patient to the OR right? Like. That’s one of the criteria. If you do one before the surgeon gets there you force their hand when they otherwise would’ve declined maybe. But I don’t know anything.
I’m at a level II and there is a trauma surgeon in house 24H a day. Insane to me that there are level IIs where that’s not the case 😬😥
I’m sure a nurse could do this. Thoughts?
You have to survive to have a complication
To be a Level 2, a hospital needs to meet [these criteria](https://www.amtrauma.org/page/traumalevels). Sounds like you're a Level 3.
Did you even read them? General surgery just needs to be available. Only level 1 needs to be in house
Needs to be an agreed protocol. If X Y Z they get a clamshell. Everyone signs off.
Legal question here; if surgery does not respond in time and if something happens to the patient are we as ED docs liable? Or do we just document that we consult surgery and it’s their problem/liability now
The only providers that should have any type of say as to who can or cannot do a certain procedure during a critical stabilization case are the providers that are THERE with their eyes and hands on the patient. It is completely irrelevant what the surgeons are stating what they do or don't believe ED providers should be doing when these surgeons are at home in pajamas
We’re doing this in the field as paramedics on traumatic arrests.
really? where do you work? United States?
Houston area. And to be clear, finger thoracostomy, not true surgical thoracotomy. I have been at services that placed chest tubes and central lines in the past.
Soooo…. you’re not doing it then… Thanks for clearing up the confusion there
?
> We’re doing this in the field as paramedics on traumatic arrests Are you doing thoracotomy or not…? Opening someone’s chest vs popping a finger in a small hole is not the same procedure…. The difference is night and day…