Japan Former PM Shinzo Abe Resuscitation Discussion

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For those not paying attention, he was the former Prime Minister of Japan who was shot and killed.

What caught my attention was reporting that at least 20 doctors were working to resuscitate him. I don’t know if the injuries were survivable; probably not.

But this may also be another example that if you are in a trauma scenario you are better off being the homeless guy than the VVIP.
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One of the photos shows someone doing CPR on him at the scene. It didn't look very good already from that picture.
 
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Details are scant but from what I've seen reported, it seems like he sustained two gunshot wounds, one to the left chest and one to the right neck and was taken to the hospital without vital signs. I can't imagine he wouldn't have received an ED thoracotomy.

I hope the 20 people weren't all in the room at the same time. At a well run trauma center that may not be an unreasonable number of docs to be "involved" in a major trauma resuscitation, though obviously not all of them are touching the patient during the initial resuscitation.

Inside the room:
HOB x 2 (intubator (EM or anesthesia) and assistant)
Right chest x 1: surgery or EM resident
Left chest x 1: surgery or EM resident
Foot of bed x 2 (EM leader, trauma chief)

Outside the room:
EM attending x 1
Trauma attending x 1
Surgery juniors x 1-2
Anesthesia attending x 1
Anesthesia resident x 2 if they are not intubating
Misc resident x 1-2 putting in orders

Depending on the situation
Ortho team x 1-2
Neurosurgery team x 1-2

That's about 20 people.
 
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When you watch the video
gro2001 said:
Details are scant but from what I've seen reported, it seems like he sustained two gunshot wounds, one to the left chest and one to the right neck
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In the video, you can see his right shirt collar move forward, a fraction of a second before you hear the blast. That's likely a bullet exiting his right neck. You see it a split second before you hear the sound, because a high velocity projectile moves faster than the speed of sound. Then, in the picture where he's laying supine on the pavement being tended to, you can see blood on his shirt overlying his left chest.

Those were not likely survivable injuries, with what is essentially a homemade shot gun with multiple projectiles, ripping through his vital organs, in a setting where they don't exactly get a lot of practice with gunshot wounds.
 
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Their society is very different from ours stateside. Gun violence is literally a foreign concept to them. I believe there was one gun related death in the year 2021. Their worst year it i recall had less than a dozen. This is a country of about 120 million people. Combine that with the fact that after WWII their military was essentially non-existent for decades and only in recent times starting to participate in global offensives for UN peacekeeping missions and you probably have ER docs and trauma surgeons who have gone decades if not entire careers without treating high velocity penetrating injuries.
 
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WuMedic said:
Their society is very different from ours stateside. Gun violence is literally a foreign concept to them. I believe there was one gun related death in the year 2021. Their worst year it i recall had less than a dozen. This is a country of about 120 million people. Combine that with the fact that after WWII their military was essentially non-existent for decades and only in recent times starting to participate in global offensives for UN peacekeeping missions and you probably have ER docs and trauma surgeons who have gone decades if not entire careers without treating high velocity penetrating injuries.
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Sounds nice.
 
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Golden Rule of trauma centers = the number of people in resuscitations is inversely proportional to the number of resuscitations performed.

The busiest places are usually at most 2-4 doctors and nurses plus a maybe a few students.
 
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Regarding the case it seems like he rapidly arrested from a GSW to his heart. Doesn't matter how many people were in the room when he arrived they weren't getting him back neurologically intact if he was pulseless for over 10min prior to arrival. Considering that even in urban settings with helicopters the average time from dispatch to arrival is 20min he was as good as dead regardless of the care administered. His only real chance would have been an EMS physician willing to perform an immediate prehospital thoracotomy like they currently do across the pond in England.
 
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Yeah

when I read 100 units of blood I immediately concluded they had no idea how to handle a GSW

why would they? 10 shootings a year, that's like asking me to manage rare tropical diseases without help.
 
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AlmostAnMD said:
Yeah

when I read 100 units of blood I immediately concluded they had no idea how to handle a GSW

why would they? 10 shootings a year, that's like asking me to manage rare tropical diseases without help.
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I'd say if they gave 100 units of RBCs and no plasma or platelets...they didn't know what they were doing.
But if they were using a massive transfusion protocol then this may be more reflective of desperation than ignorance?
 
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WilcoWorld said:
I'd say if they gave 100 units of RBCs and no plasma or platelets...they didn't know what they were doing.
But if they were using a massive transfusion protocol then this may be more reflective of desperation than ignorance?
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I’m not EM or Crit Care but I would have to imagine any hospital capable of pushing 100 units of blood rapidly would have to at least have some idea of how to do it, right? Or is that something the blood bank at any podunk hospital has on hand?

I mean they may not have a lot of GSWs in Japan but I bet they still have plenty of MVCs, massive GI bleeds and don’t forget injuries from all those wacky ass game shows!
 
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Most hospitals (even trauma centers) don't have 100 units of blood on hand in today's world. There's a shortage of blood products.

I do believe it was an act of desperation that no ordinary citizen would've received. Who wants to be the doc that gives up on the former PM and have his care questioned for not doing enough?

The prehospital thoracotomy survival rate is pretty good in the UK (at least with London HEMS). Survival to hospital discharge is 18% with 77% being neurologically intact. Granted the majority are penetrating wounds from stab wounds (not GSWs). East of London Ambulance Service published abysmal results with it, but there were a lot of blunt injuries in their study mix. I think US-based prehospital thoracotomies have a 7% survival to discharge rate. The Netherlands has also published abysmal results (I think 1 patient survived to discharge in their 5+ year study).
 
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Is there any data on a threshold of transfusions that predict futility? I would have to imagine that after a certain # of rapidly transfused units, provided it's done rapidily over a short period vs in a controlled manner over 12-24 hrs, the metabolic milieu probably becomes too compromised to support hemostasis and recovery, right?

Although I highly doubt there's any data considering the rarity and heterogeneity involved.
 
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southerndoc said:
Most hospitals (even trauma centers) don't have 100 units of blood on hand in today's world. There's a shortage of blood products.

I do believe it was an act of desperation that no ordinary citizen would've received. Who wants to be the doc that gives up on the former PM and have his care questioned for not doing enough?

The prehospital thoracotomy survival rate is pretty good in the UK (at least with London HEMS). Survival to hospital discharge is 18% with 77% being neurologically intact. Granted the majority are penetrating wounds from stab wounds (not GSWs). East of London Ambulance Service published abysmal results with it, but there were a lot of blunt injuries in their study mix. I think US-based prehospital thoracotomies have a 7% survival to discharge rate. The Netherlands has also published abysmal results (I think 1 patient survived to discharge in their 5+ year study).
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I imagine the majority of penetrating trauma being stab wounds is going to make a difference in terms of survival rates. Ricochet, tumbling, and cavitation are going to create injuries that are harder to stabilize.

Also, agree in VIP angle to resuscitation. When Elvis died, they coded him for hours.
 
southerndoc said:
Considering he was dead, I'm sure it was. Whether it was checked is a different question.
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Well, due to sepsis bundle compliance, we're going to need to have you meet with our sepsis nurse for remedial training. /s
 
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AlmostAnMD said:
Yeah

when I read 100 units of blood I immediately concluded they had no idea how to handle a GSW

why would they? 10 shootings a year, that's like asking me to manage rare tropical diseases without help.
Click to expand...

Yea but the guy was the ex-president of the country. Still 100 U was not justified but are you going to call the code after 4U?

Say Bush or Obama (pick whatever president you really like) comes into your ER with a GSW. You calling it after 4U? You are not going to call it at all. You are going to do what your trauma attending wants you to do.
 
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Apollyon said:
Or, YOU are the attending.
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uhhhhhh...yea......if I'm the ER attending and the president of the US comes into my ER with a GSW to the head...I'm deferring all things to the trauma attending unless it's ridiculous. Like if he wants me to try to do a PO trial on a GSW to the brain in the ER, I would politely say no. LOL
 
coffeebythelake said:
probably not data for reference,
but common sense dictates that the faster the blood loss, the larger the volume of loss, and more hemodynamically unstable the more likely = death
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I've heard reliable accounts of postpartum hemorrhage that used 100 units pRBCs and I've seen people get 40 units and survive to discharge.
 
Apollyon said:
Or, YOU are the attending.
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Yeah … granted I’m at a level III joke of a “trauma center” and potus would not be brought to me .. but I can’t get a hold of two of my “trauma call” surgeons, ever. Luckily we have one that’s a bada$$ that helps if we actually need a stat trauma surgeon.
 
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CoolDoc1729 said:
Yeah … granted I’m at a level III joke of a “trauma center” and potus would not be brought to me .. but I can’t get a hold of two of my “trauma call” surgeons, ever. Luckily we have one that’s a bada$$ that helps if we actually need a stat trauma surgeon.
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The beauty of the Secret Service is that all of that is planned out a priori. The painful part is that means you may be down multiple resources (rooms, units of blood, OR suite, etc.) due to very serious men with guns telling you they’re reserved in the event something happens to the package.
 
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TJRock said:
Or if they did a Covid test. This may be another Covid death.
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Lame sauce dude. I know this was supposed to be a joke, but those "fake" covid death stories were malicious misinformation. Let's not turn this thread into THAT argument, please.
 
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Arcan57 said:
The beauty of the Secret Service is that all of that is planned out a priori. The painful part is that means you may be down multiple resources (rooms, units of blood, OR suite, etc.) due to very serious men with guns telling you they’re reserved in the event something happens to the package.
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Yeah, last time a POTUS had an event near my Level 1 center the Secret Service was in the ED before the event even started & the elevator that most quickly led to the OR was kept reserved for the duration of the event. POTUS is not going to show up at an ED without a Trauma Surgeon in house.
 
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Since they gave 100 units PRBCs, just as a thought experiment…

What if you cannulated someone to ecmo and just slammed 100 units of blood through the ecmo circuit? probably a very poor utilization of resources but from a purely academic prospective I wonder if it would work. Could buy the surgeons enough time to do a clamshell and close the hole in the ventricle.
 
The Knife & Gun Club said:
Since they gave 100 units PRBCs, just as a thought experiment…

What if you cannulated someone to ecmo and just slammed 100 units of blood through the ecmo circuit? probably a very poor utilization of resources but from a purely academic prospective I wonder if it would work. Could buy the surgeons enough time to do a clamshell and close the hole in the ventricle.
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basically the polar opposite of hemostatic resuscitation
 
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The Knife & Gun Club said:
Since they gave 100 units PRBCs, just as a thought experiment…

What if you cannulated someone to ecmo and just slammed 100 units of blood through the ecmo circuit? probably a very poor utilization of resources but from a purely academic prospective I wonder if it would work. Could buy the surgeons enough time to do a clamshell and close the hole in the ventricle.
Click to expand...

Use of ECMO in penetrating traumatic arrest isn't unheard of, though it's certainly not common. When it happens it's after the ER thoracotomy but before definitive repair. It takes most people who's name isn't Yannopoulus quite a bit longer to put someone on the circuit than it does to open the chest. Then again, Japan has lots of people experienced with ECPR and very few with ER thoracotomies, so maybe you're onto something.
 
WilcoWorld said:
Yeah, last time a POTIS had an event near my Level 1 center the Secret Service was in the ED before the event even started & the elevator that most quickly led to the OR was kept reserved for the duration of the event. POTUS is not going to show up at an ED without a Trauma Surgeon in house.
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They can only do what you allow them to do. It's private property. They can't force you to reserve rooms and reserve elevators. However, object at your own peril.
 
southerndoc said:
They can only do what you allow them to do. It's private property. They can't force you to reserve rooms and reserve elevators. However, object at your own peril.
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Sounds like a good way to get drowned in weekly site visits until the hospital crumbles.
 
southerndoc said:
They can only do what you allow them to do. It's private property. They can't force you to reserve rooms and reserve elevators. However, object at your own peril.
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I wasn't complaining. Just making the point that POTUS is highly unlikely to get a PODUNK resuscitation team.
 
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HemeOncHopeful19 said:
Sounds like a good way to get drowned in weekly site visits until the hospital crumbles.
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It's more about the perils of dealing with people with law enforcement powers that have very little sense of humor and truly believe that their actions are vital to protecting the free world.
 
This whole case reminds me of when the CEO of my hospital brought his dad in following a hip dislocation. The dad was also in Afib RVR. Before he even arrived with his dad, he had called the ortho attending to reduce the hip and called cards for the Afib. The entire ER was swarming with several nurses and other ancillary staff, all attending to this one guy. It was quite a scene. It made me realize few people even know what we do as ER physicians.

I got a card from him weeks later, thanking me for all my help. Not quite sure if I was the actual target of that card.
 
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Kryptocoin said:
This whole case reminds me of when the CEO of my hospital brought his dad in following a hip dislocation. The dad was also in Afib RVR. Before he even arrived with his dad, he had called the ortho attending to reduce the hip and called cards for the Afib. The entire ER was swarming with several nurses and other ancillary staff, all attending to this one guy. It was quite a scene. It made me realize few people even know what we do as ER physicians.

I got a card from him weeks later, thanking me for all my help. Not quite sure if I was the actual target of that card.
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I hate hate hate hate hate when the pseudo VIP patients show up ie important to someone important but not actually important like the CNOs aunt Betsy or whatever. If I get a call from my boss at 2300 it’s 100% guaranteed to be this and it’s so annoying.

The worst was when we routinely had 24 hour waits in the wr during one of the covid waves and there was an outbreak at corporate. They roomed these stable people and their spouses ahead of nstemis in the wr , so they could get the antibody treatment 🙄

Also how often does the ortho attending reduce a hip in the ER? Did they have anesthesia sedate? It’s irritating to me that these management people think the system as set up doesn’t actually work, but it’s good enough for the rest of us. Whereas I believe the system generally at least sort of works, and trying to go around the normal protocols often causes harm.
 
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CoolDoc1729 said:
I hate hate hate hate hate when the pseudo VIP patients show up ie important to someone important but not actually important like the CNOs aunt Betsy or whatever. If I get a call from my boss at 2300 it’s 100% guaranteed to be this and it’s so annoying.

The worst was when we routinely had 24 hour waits in the wr during one of the covid waves and there was an outbreak at corporate. They roomed these stable people and their spouses ahead of nstemis in the wr , so they could get the antibody treatment 🙄

Also how often does the ortho attending reduce a hip in the ER? Did they have anesthesia sedate? It’s irritating to me that these management people think the system as set up doesn’t actually work, but it’s good enough for the rest of us. Whereas I believe the system generally at least sort of works, and trying to go around the normal protocols often causes harm.
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Big pet peeve of mine too.

That ortho attending is rarely, if ever, in the ED. In 4 yrs, I've only seen him once in the ED. We do own sedation, but in this case, anesthesia showed up for the sedation.

And you're right. All that use of resources didn't change the outcome. He got rate controlled, and his hip reduced. Something any competent ED doctor can do alone.

On the positive side, my charting was very brief and easy. Not a lot to say, when you didn't do much.
 
Kryptocoin said:
Big pet peeve of mine too.

That ortho attending is rarely, if ever, in the ED. In 4 yrs, I've only seen him once in the ED. We do own sedation, but in this case, anesthesia showed up for the sedation.

And you're right. All that use of resources didn't change the outcome. He got rate controlled, and his hip reduced. Something any competent ED doctor can do alone.

On the positive side, my charting was very brief and easy. Not a lot to say, when you didn't do much.
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Probably still billed for CC, though? (no shame. I def would have)
 
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turkeyjerky said:
Probably still billed for CC, though? (no shame. I def would have)
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If everyone else is going to charge, there's no shame in getting our cut of the insurance pinata.
 
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