Thoracotomies in the ER?

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Ezekiel20

Ezekiel20

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Hi all,

I am a local Aussie med student studying at Sydney University.

I'm currently doing a 4-week ED rotation, of which I've completed 2 weeks.

Despite being the 3rd busiest ED in the state (3 resus bays, ~30 acute beds, ~15 short stay beds), life in the ED is quite dull. Mostly medical complaints, some road accident trauma, occasional stabbing etc.

And it just happens that I've watched a fair bit of the NBC TV show 'ER', and I couldn't help but notice that in the show they do an awful lot of thoracotomies (often followed by internal defibrillation).

So I decided to risk looking silly, and ask whether they actually perform thoracotomies in the ER in the States - or whether this is just something the TV producers made up for dramatic effect. In the Aussie ED, pleural taps are probably as invasive as they come..

Of course I'm not naive enough to believe what I see on TV shows, but given the differences between the US and Aussie medical system, I thought maybe the American ER docs are a cross between Aussie ED docs and trauma surgeons (the Aussie ED docs are pretty much physicians).

Thanks in advance,
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ED thoracotomies are rather uncommon, even at a busy ED that recieves large amounts of penetrating trauma. I've been told the only really viable indication for them is cardiac arrest secondary to penetrating trauma that occurs as the victim arrives at the ED, or shortly thereafter. Survival is, of course, rather low.

The American Heart Association suggested the following guidelines in 2005:

Blunt trauma
• Patient arrives at ED or trauma center with pulse, blood pressure, and spontaneous respirations, and then experiences witnessed cardiac arrest

Penetrating cardiac trauma
• Patient experiences a witnessed cardiac arrest in ED or trauma center or
• Patient arrives in ED or trauma center after <5 minutes of out-of-hospital CPR and with positive secondary signs of life (eg, pupillary reflexes, spontaneous movement, organized ECG activity)

Penetrating thoracic (noncardiac) trauma
• Patient experiences a witnessed cardiac arrest in ED or trauma center or
• Patient arrives in ED or trauma center after <15 minutes of out-of-hospital CPR and with positive secondary signs of life (eg, pupillary reflexes, spontaneous movement, organized ECG activity)

Exsanguinating abdominal vascular trauma
• Patient experiences a witnessed cardiac arrest in ED or trauma center or
• Patient arrives in ED or trauma center with positive secondary signs of life (eg, pupillary reflexes, spontaneous movement, organized ECG activity) plus • Resources available for definitive rep
air of abdominal-vascular injuries

See this for source.
 
I've seen one, and was told by the ER docs that it was very uncommon. The most prolific of the group had done about twenty over his thirty-year career; the one I saw was the first in this (rather busy) ER in two years.

The case: Police officer shot twice at close range with a .22 caliber rifle. One bullet hit near or at the left subclavian, the other at the distal inferior vena cava. He was brought into the ER with no vitals, eight units of blood given without effect. The thoracotomy was done in the trauma bay and the ER doc did cardiac massage while the trauma surgeon explored for the source of the bleeding, but by then it was of course far too late; he had bled out well before he got into the ER.

Totally tangential to thoracotomies, but an interesting twist to this story: Another police officer was shot at the same time, in just about the same superficial anatomical location, but was discharged the next day: the bullet hit his right clavicle and shattered.
 
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I've seen at a couple of times at the urban, county ED where we rotate through. It is pretty unusual but we have A LOT of trauma and a very high percentage of that is gunshot wounds and other penetrating trauma. Don't think either person survived and I believe my resident told my the survival rate for ED thoracotamies is very low. It's a salvage procedure.
 
pillowhead said:
I've seen at a couple of times at the urban, county ED where we rotate through. It is pretty unusual but we have A LOT of trauma and a very high percentage of that is gunshot wounds and other penetrating trauma. Don't think either person survived and I believe my resident told my the survival rate for ED thoracotamies is very low. It's a salvage procedure.
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Extremely low survival rate, which I've heard quoted as 1%-5% (based on what their mechanism of injury was).

I did go to med school in "the most dangerous city in the US," and I saw a few ER Thoracotomies, all of which (for the most part) followed the above-mentioned protocol. 2/3 were GSW to chest, the other one was blunt chest trauma with loss of vitals in the trauma bay. Of course, they all died.

Thankfully, in sunny Wichita, KS, the bullets don't fly by quite as often, and I've only seen one (albeit on a GSW to chest).

Whenever someone says, "we cracked a chest in the ER last night," most people reply "so they died, then?" To which the response is, "Yep."
 
Thanks all of you - it's great to know!
 
i saw two in three weeks on trauma -- and every student i know has seen at least one. we're at a big county hospital though, and one of the busiest trauma centers in the us (LAC+USC). they're pretty amazing. everyone gathers around and the ED doc is barking orders at everyone while the trauma surgeons gown up. most of these patients, unfortunately, do not do well.
 
I've never seen one, but my attending told me that it should be done more often because it can save lives
 
ericdamiansean said:
I've never seen one, but my attending told me that it should be done more often because it can save lives
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I would think the data (to do ED thoracotomies) only supports that as noted above. Perhaps in some arenas, it isn't done as often as it should be, although I would counter it actually is done more than necessary (ie, in the blunt trauma without vitals several minutes out) for teaching purposes. It may save lives, but the chances are minimal for most done. Only in the appropriate setting would the patient have a chance of surviving. We can discuss how appropriate it is to crack every chest that comes in with a penetrating or blunt trauma to save what...one in a hundred, one in two hundred?

I've never seen one and would object to doing one for such reasons (ie, teaching), although the appropriate situation (we had vastly more blunt than penetrating) never arose. That said, those who train at some of the big trauma centers see them quite regularly, especially when the trauma occurs within blocks of the hospital (ours were many miles away generally - so usually DOA if even brought to us...they usually went to the downtown hospital, not a trauma center, but much closer to the action).
 
LukeWhite said:
I've seen one, and was told by the ER docs that it was very uncommon. The most prolific of the group had done about twenty over his thirty-year career; the one I saw was the first in this (rather busy) ER in two years.

The case: Police officer shot twice at close range with a .22 caliber rifle. One bullet hit near or at the left subclavian, the other at the distal inferior vena cava. He was brought into the ER with no vitals, eight units of blood given without effect. The thoracotomy was done in the trauma bay and the ER doc did cardiac massage while the trauma surgeon explored for the source of the bleeding, but by then it was of course far too late; he had bled out well before he got into the ER.

Totally tangential to thoracotomies, but an interesting twist to this story: Another police officer was shot at the same time, in just about the same superficial anatomical location, but was discharged the next day: the bullet hit his right clavicle and shattered.
Click to expand...

I've seen one as well on my two weeks in the ER. GSW to the chest. Apparently he had fem pulses in the field. Everyone was crowded in the shock room as the surgeon and residents were trying to localize the bleeding. They stuck a foley in his left atrium, but it didn't work. The most amazing thing about the situation was the anatomy lesson that followed. Definitely tops first year anatomy!
 
I've seen a few including clamshells (bilateral thoractomies). I know at our county hospital, we once had two come in and get thoracotomies in the trauma bay and survive in the same night (Both were penetrating traumas, and of course, I was post-call and missed it myself, but they BOTH went onto having meaningful recoveries.) That was the first time in a long time (months to years) that had happened on our trauma service, as most who are revived with the thoractomy seem to die once in the OR.

Our trauma service does them fairly often, but many times it is more for teaching purposes (i.e. given the extent of injury) than actually thinking that the person is salvagable...
 
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MadameLULU said:
hey stuck a foley in his left atrium, but it didn't work.
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So they died? (that's how I respond to all ER thoracotomy stories)

I love the foley-in-the-heart-hole trick. Never seen it work at all, but it's very MacGyver-ish, and residents are dying for an opportunity to suggest it.....
 
One of my peers saw one during our month long rotation at Detroit Receiving, where they are not very uncommon. In fact, I seem to remember there being one in an episode of "Trauma:Life in the ER" filmed at Receiving where they later went on to show the patient walking out of the hospital. Unfortunately my friend's patient died in the OR.

One of the old school trauma attendings one day was sharing the sentiment of ericdamiansean's attending, that they are lifesaving and should be performed more often. In fact, he told a story of a surgeon he knew who arrived at the hospital to be told his daughter was dead s/p MVA. He pushed past those taking care of her and personally performed a thoracotomy which ultimately saved her life. I found this hard to believe, but that was the story.
 
SLUser11 said:
So they died? (that's how I respond to all ER thoracotomy stories)

I love the foley-in-the-heart-hole trick. Never seen it work at all, but it's very MacGyver-ish, and residents are dying for an opportunity to suggest it.....
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Interesting side note to the Foley in heart...

when studying for boards, SESAP and other sources said specifically NOT to use the Foley, it can make the hole bigger. Rather use your finger, have it prepped in on the trip to the OR (ie, assume you are keeping your finger in there from the trauma bay to the OR) and remove only when the stitch is placed through. Of course, it would hurt the Foley balloon a lot less if the stitch caught it rather than youe finger...:D
 
Kimberli Cox said:
Interesting side note to the Foley in heart...

when studying for boards, SESAP and other sources said specifically NOT to use the Foley, it can make the hole bigger. Rather use your finger, have it prepped in on the trip to the OR (ie, assume you are keeping your finger in there from the trauma bay to the OR) and remove only when the stitch is placed through. Of course, it would hurt the Foley balloon a lot less if the stitch caught it rather than youe finger...:D
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What about using a skin stapler? I've seen it done for ventricular wounds, but I don't recalls seeing it used on the atria.......
 
DropkickMurphy said:
What about using a skin stapler? I've seen it done for ventricular wounds, but I don't recalls seeing it used on the atria.......
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Certainly would work...but for some reason, the "finger in the hole" seems to be the board answer. Since suction isn't as readily available, I would imagine it might be difficult to do easily in the trauma bay. I'll have to look back at SESAP again and see if there isn anything about stapling.
 
I saw several on my three weeks of trauma (gotta love LA, where if you are shot or stabbed you have a greater chance of survival if you get some buddies to take you to the hospital instead of waiting for an ambulance-uh, unless it happens near King-Drew AKA King-Harbor). The one that got me most was a guy that had been talking to me and wanted to give me a phone number to call his girlfriend (he seemed fairly stable at first) that ended up crumping. I felt kinda bad that I didn't take a minute to get that number (and maybe be able to pass on a last message to her) because I was doing student-y things. Another interesting one doesn't really qualify as an ER thoracotomy because it was done in the hallway outside the OR. I was doing internal cardiac masage as they quickly brought the gurney in and they ended up bashing my pelvis between the wall and the gurney (fun stuff for the start of a long call day). I did kept massage as they worked on his abdomen, until blood started pouring out of his chest every time his lungs expanded. I called the teams attention to it and they tried to find the hole. Turned out he was bleeding from his spine too.

They highly exaggerate all aspects of EM in the show ER, but it wouldn't be as entertaining if they made each shift more realistic
 
here if you are shot or stabbed you have a greater chance of survival if you get some buddies to take you to the hospital instead of waiting for an ambulance
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The Homeboys Ambulance Service- "When you absolutely positively just got a cap busted in yo' ass." :laugh:
 
As a student, I saw one at a smaller affiliate hospital - a man stabbed with a knife in the left chest, penetrating the heart. The ER was a circus for about 4 hrs, and I couldn't see anything. Sadly he did not survive.
 
Very rare. As above, it happens.. Depends on what your volume and trauma status is for the ED. We do a couple a year here, penetrating trauma.


Not to long ago, an attending and resident did one for a ruptured AAA. Definately not indicated but the guy was going to die. Resident went to the or with her hand tightly on the descending aorta. He walked out of the hospital.
 
roja said:
Resident went to the or with her hand tightly on the descending aorta. He walked out of the hospital.
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That's cool:laugh:

The furthest I had gone was putting my hand up some dead guy's brain from the thorax (they had removed the lungs etc)
 
one of my attendings did 100 ed thoracotomies as a resident and recently told me he thought our facility should do more. sure enough the next day he does one in the dept. his save figures are in line with national figures. he has had 2 saves out of a little over 100 total.
 
emedpa said:
one of my attendings did 100 ed thoracotomies as a resident and recently told me he thought our facility should do more. sure enough the next day he does one in the dept. his save figures are in line with national figures. he has had 2 saves out of a little over 100 total.
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2 out of 100 lives saved?
 
ericdamiansean said:
2 out of 100 lives saved?
Click to expand...

Yes and so what? CPR survival is not much better, yet it is the standard of care. When you are playing a numbers game the survival rate makes it hardly seem worth it, but looking at an individual grandparent, mother, father or child, you want to know you gave the that chance. We should probably do more of them. Moreover, I personally am also of the opinion that the survival rates on EDTs and EDLs would be much better if we did them sooner rather than later.


References :D
Emergency thoracotomy in trauma: rationale, risks, and realities.
Scand J Surg. 2007;96(1):4-10. Review.
PMID: 17461305 [PubMed - indexed for MEDLINE]

Long-term survival after successful inhospital cardiac arrest resuscitation.
Am Heart J. 2007 May;153(5):831-6.
PMID: 17452161 [PubMed - indexed for MEDLINE]

The optimum timing of resuscitative thoracotomy for non-traumatic out-of-hospital cardiac arrest.
Resuscitation. 1993 Aug;26(1):69-74.
PMID: 8210734 [PubMed - indexed for MEDLINE]
 
Hard24Get said:
Yes and so what? CPR survival is not much better, yet it is the standard of care. When you are playing a numbers game the survival rate makes it hardly seem worth it, but looking at an individual grandparent, mother, father or child, you want to know you gave the that chance. We should probably do more of them. Moreover, I personally am also of the opinion that the survival rates on EDTs and EDLs would be much better if we did them sooner rather than later.


References :D
Emergency thoracotomy in trauma: rationale, risks, and realities.
Scand J Surg. 2007;96(1):4-10. Review.
PMID: 17461305 [PubMed - indexed for MEDLINE]

Long-term survival after successful inhospital cardiac arrest resuscitation.
Am Heart J. 2007 May;153(5):831-6.
PMID: 17452161 [PubMed - indexed for MEDLINE]

The optimum timing of resuscitative thoracotomy for non-traumatic out-of-hospital cardiac arrest.
Resuscitation. 1993 Aug;26(1):69-74.
PMID: 8210734 [PubMed - indexed for MEDLINE]
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That's true, so someone should start doing a whole lot more of it
 
This week on my second night of my internship (my first call), TWO ED thoracotomies. On the second one, after the foley in the hole my senior called for fluids to be pushed through the foley cath directly into the heart. It looked really cool, not that it worked (guy was done for before he even got to us).
 
A finger is much better for atrial wounds than a staple because the atria is more friable than the ventricle, and staples that may hold in the ventricle may tear through, making an atrial hole bigger.



Winged Scapula said:
Certainly would work...but for some reason, the "finger in the hole" seems to be the board answer. Since suction isn't as readily available, I would imagine it might be difficult to do easily in the trauma bay. I'll have to look back at SESAP again and see if there isn anything about stapling.
Click to expand...
 
I've seen one ... auto accident during my two weeks of trauma. Afterwards the attending said where is the med student. Here sew him back up we can't send them to the morgue open. Handed me a giant autopsy needle and I got to work.
 
My program doesn't even train us on them anymore and our trauma surgeons rarely do them. We also don't have a lot of penetrating trauma, so it's somewhat understandable, which has like 3-5x the survival rate of using it in blunt trauma per my Tintinalli. Means I might have to use my elective time for a trauma rotation at a busier urban place.
 
You have to keep in mind that doing them against the odds for "teaching purposes" comes with the substantial risk of contracting infectious diseases. By and large, penetrating trauma pts tend to have a high rate of badness going on, especially things like Hep C and HIV.

Given that you're cracking ribs, whipping around needles and other sharp instruments, and sticking your arms pretty deep into the chest cavity, you're risk of a penetrating injury to yourself goes up exponentially.

Not only that, but your chances of getting sued go up as well. Mistakes made during or after the procedure open you up to malpractice, especially if you're going cowboy and trying a variety of stuff out. On the flip side, there's not much of a case against you if you refrain from doing an ED thoracotomy that isn't indicated.

Now with all this said, I'm not saying you should hold back from doing a procedure if it's indicated and truly in the best interest of the pt, however, there are very real personal and financial risks for going ahead with it for any other reason.
 
I had seen a bunch, but never got any formalized teaching on how to do it. Before I started doing night float I read the chapter in Top Knife that deals with ED thoracotomy (at night there is no in house attending, so for as long as it takes for them to get there from home after you call them, you are the senior surgeon-figured I should read up on the emergency stuff I might need to do). One night we had a case where it was indicated, so I took a deep breath and did it. Some of our ED attendings are pretty helpful when it comes to trauma and luckily this was one of those times, but no one was giving me step by step instructions. It wasn't as hard as I thought it would be, and I managed not to injure anything on myself or the patient. Guy stayed dead though. What helped me stay calm during, was the realization that he was dead, and I was trying to bring him back to life (was less stressful to me since you can't make anyone worse than dead).
 
Bump

I was looking up some of the figures for London's Air Ambulance, and they quote up to a 20% survival rate for in field thoracotomies. That's pretty outstanding when we are only achieving a 1-5% survival rate here....in hospital. Now, I don't know if their criteria is just stricter, or if it really is working better. They also quoted a 50% decrease in all trauma fatalities in the London area since the programs inception. I'm just a MS-1, so I don't know much, but this sounds pretty amazing to me.

Anyone have any thoughts on using physician based pre-hospital care in the state? I would assume costs are a limiting factor, and I dont want to get into an RN-vs-midlevel-doctor debate (about who is better for staffing).
 
I worked as a paramedic for 7 years in a busy urban EMS system that used EM residents staffed 24/7. It was hit or miss using the residents. A new second year EM resident only hurt things. A resident finishing up his program was often an asset. I've worked with medical directors (er attendings) in the field. Very much an asset. But in reality there was probably not much improvement in outcome. I believe one of the local ER attending docs' family member commited suicide and he did a thoracostomy in the house before calling 911, without success.
 
bsloane said:
Bump

I was looking up some of the figures for London's Air Ambulance, and they quote up to a 20% survival rate for in field thoracotomies. That's pretty outstanding when we are only achieving a 1-5% survival rate here....in hospital. Now, I don't know if their criteria is just stricter, or if it really is working better. They also quoted a 50% decrease in all trauma fatalities in the London area since the programs inception. I'm just a MS-1, so I don't know much, but this sounds pretty amazing to me.

Anyone have any thoughts on using physician based pre-hospital care in the state? I would assume costs are a limiting factor, and I dont want to get into an RN-vs-midlevel-doctor debate (about who is better for staffing).
Click to expand...

I would say a big limiting factor is resources. We don't have nearly the amount of toys to play with in the field that are available to a doc in the ED.
 
OP, thoracotomies are reasonably common in London. Usually poor outcomes, but a load are done on scene by the air ambulance.
 
sineapse said:
OP, thoracotomies are reasonably common in London. Usually poor outcomes, but a load are done on scene by the air ambulance.
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Which is something that I hope will catch on here in the US.

A couple of things...

The Trauma East guidelines for ED Thoracotomy are different than those listed earlier in the thread. They're much broader: http://www.trauma.org/archive/thoracic/EDTindications.html. Specifically:

Accepted Indications
Penetrating thoracic injury:
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
- Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury
- Unresponsive hypotension (BP < 70mmHg)
- Rapid exsanguination from chest tube (>1500ml)

Relative Indications
Penetrating thoracic injury
- Traumatic arrest without previously witnessed cardiac activity
Penetrating non-thoracic injury
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
Blunt thoracic injuries
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications
Blunt injuries
- Blunt thoracic injuries with no witnessed cardiac activity
- Multiple blunt trauma
- Severe head injury

Now I'm not an authority, but I'd add an indication here: WITNESSED traumatic arrest OR unresponsive hypotension (BP < 70mmHg) from penetrating OR blunt abdominal trauma. Why? What's one of (yes, it's the last, but one of nonetheless) purposes of an ED Thoracotomy? Cross-clamping the descending thoracic aorta. You can save someone's life from essentially sudden and near-complete hemorrhage from penetrating OR blunt abdominal trauma by doing so.

Back to your run-of-the-mill thoracotomies, IF done correctly (correct indications, and immediately upon presentation), the prognosis isn't as dismal as most people cite (0.5% - 2%). According to Dr. Seamon of Temple University, "Overall, 10% of patients with gunshot wounds survived and 7% with multiple gunshot wounds survived. Additionally, 6% of patients without measurable vitals signs, 5% of patients without ED signs of life, and 7% of patients who cardiac rhythms were documented as non-salvageable survived. In all, 30% of the survivors lacked three of the six positive predictors of survival, and one survivor lacked all three predictors." More can be found here: http://www.facs.org/surgerynews/2007/1007.pdf

sineapse, back to your point. Correct me if I'm wrong, but from what I've read, in London, every major trauma that prompts air response has a doctor on board. And the goal of this is to bring medical care to the patient, and actually stabilize the patient in the field, prior to beginning transport to the Trauma Facility. This includes performing many invasive procedures in the field that are otherwise only performed in the ED. In particular, thoracotomies for witnessed penetrating trauma (yes, they do prehospital thoracotomies in London). This is in STARK contrast with the US EMS theme which primarily consists of EMTs & Paramedics only, and follows the "Load 'n Go" concept - get there, load 'em into the transporter (air or ground) and get to the hospital ASAP, doing only the absolute minimum interventions required en-route.

IMO, the London-based approach only makes sense, because the thoracotomy will make the biggest difference at the time of cardiac arrest or hemodynamic instability. Transporting an arrest with CPR in progress (which at best only provides 1/3 of circulation, assuming you don't have tamponade and overwhelming hypovolemia) for 20+ minutes, then debating about what to do for the next 5 minutes, then performing the thoracotomy...it's no wonder the survival rate is often reported as being dismal.

The earlier the thoracotomy is performed, the better the prognosis, or so it seems. But hey, don't take it from me. Take it from the London docs, who are apparently having great success rates with it, IN THE FIELD: http://www.ncbi.nlm.nih.gov/pubmed/21131854.

Again, I only hope this proves to be something that will catch on here in the US.

EDIT: PS: And yes, I've done a few. And we've had a few survive, at that...
 
FDNewbie said:
Which is something that I hope will catch on here in the US.

A couple of things...

The Trauma East guidelines for ED Thoracotomy are different than those listed earlier in the thread. They're much broader: http://www.trauma.org/archive/thoracic/EDTindications.html. Specifically:

Accepted Indications
Penetrating thoracic injury:
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
- Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury
- Unresponsive hypotension (BP < 70mmHg)
- Rapid exsanguination from chest tube (>1500ml)

Relative Indications
Penetrating thoracic injury
- Traumatic arrest without previously witnessed cardiac activity
Penetrating non-thoracic injury
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
Blunt thoracic injuries
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications
Blunt injuries
- Blunt thoracic injuries with no witnessed cardiac activity
- Multiple blunt trauma
- Severe head injury

Now I'm not an authority, but I'd add an indication here: WITNESSED traumatic arrest OR unresponsive hypotension (BP < 70mmHg) from penetrating OR blunt abdominal trauma. Why? What's one of (yes, it's the last, but one of nonetheless) purposes of an ED Thoracotomy? Cross-clamping the descending thoracic aorta. You can save someone's life from essentially sudden and near-complete hemorrhage from penetrating OR blunt abdominal trauma by doing so.

Back to your run-of-the-mill thoracotomies, IF done correctly (correct indications, and immediately upon presentation), the prognosis isn't as dismal as most people cite (0.5% - 2%). According to Dr. Seamon of Temple University, "Overall, 10% of patients with gunshot wounds survived and 7% with multiple gunshot wounds survived. Additionally, 6% of patients without measurable vitals signs, 5% of patients without ED signs of life, and 7% of patients who cardiac rhythms were documented as non-salvageable survived. In all, 30% of the survivors lacked three of the six positive predictors of survival, and one survivor lacked all three predictors." More can be found here: http://www.facs.org/surgerynews/2007/1007.pdf

sineapse, back to your point. Correct me if I'm wrong, but from what I've read, in London, every major trauma that prompts air response has a doctor on board. And the goal of this is to bring medical care to the patient, and actually stabilize the patient in the field, prior to beginning transport to the Trauma Facility. This includes performing many invasive procedures in the field that are otherwise only performed in the ED. In particular, thoracotomies for witnessed penetrating trauma (yes, they do prehospital thoracotomies in London). This is in STARK contrast with the US EMS theme which primarily consists of EMTs & Paramedics only, and follows the "Load 'n Go" concept - get there, load 'em into the transporter (air or ground) and get to the hospital ASAP, doing only the absolute minimum interventions required en-route.

IMO, the London-based approach only makes sense, because the thoracotomy will make the biggest difference at the time of cardiac arrest or hemodynamic instability. Transporting an arrest with CPR in progress (which at best only provides 1/3 of circulation, assuming you don't have tamponade and overwhelming hypovolemia) for 20+ minutes, then debating about what to do for the next 5 minutes, then performing the thoracotomy...it's no wonder the survival rate is often reported as being dismal.

The earlier the thoracotomy is performed, the better the prognosis, or so it seems. But hey, don't take it from me. Take it from the London docs, who are apparently having great success rates with it, IN THE FIELD: http://www.ncbi.nlm.nih.gov/pubmed/21131854.

Again, I only hope this proves to be something that will catch on here in the US.

EDIT: PS: And yes, I've done a few. And we've had a few survive, at that...
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Yes, it is a physician (anaesthetists or EM doctors at registar/consultant level) + paramedic response. I've spent some time in the ER with one of the guys that wrote that paper, he basically set up the air ambulance in London.

It does make sense from what you describe, but bear in mind that there will be delays from the time of dispatch to arrival of the air ambulance, assessment and intervention that can be delayed. For example, a land ambulance may arrive at scene and delay transport of the pt. until the helicopter has arrived, potentially affecting outcome.

I know most air ambulances in the US are nurse-led (why not paramedic?) but I did see an EM programme at Cincinnati where the residents flew in their air ambulance to trauma calls....looked great!
 
sineapse said:
Yes, it is a physician (anaesthetists or EM doctors at registar/consultant level) + paramedic response. I've spent some time in the ER with one of the guys that wrote that paper, he basically set up the air ambulance in London.
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Lucky you. Could you clarify what you mean by EM doctor? Cuz my understanding is that in Europe, the ER is called A&E (Accident & Emergency), and it's run mostly by Orthopedic & Trauma Surgeons. Vs. here in the US, our ERs are run by Emergency Medicine doctors, who really aren't specialists in any one particular field, but have mastered the emergent skills required in several different professions (some surgical interventions, some medical interventions, some orthopedic interventions, some anesthesia interventions, some OB/GYN interventions, etc). But we don't get actual surgical training per se. And it's my belief that this is one of the major underlying reasons for ER docs here in the US to be so reluctant to perform thoracotomies - while it is well within our scope of practice, it simply isn't something we're given any formal training on how to do. I'd imagine this is a bit different in Europe.

It does make sense from what you describe, but bear in mind that there will be delays from the time of dispatch to arrival of the air ambulance, assessment and intervention that can be delayed. For example, a land ambulance may arrive at scene and delay transport of the pt. until the helicopter has arrived, potentially affecting outcome.
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I read ya loud & clear. But I remember the documentary I watched online (can't find it now as luck would have it) mentioned how in the busy streets of London, even if a ground crew could - and often does - get there before the air team, their ground transport times were quite extended - to the tune of 40 minutes to so - to get to the nearest major Trauma Center. Hence why air is routinely dispatched, and while stabilization upon arrival was emphasized. As we all know, air takes quite a significant amount of time in it of itself (to find a landing zone, actually land, spin down, for you to get to the scene, transport back to the helicopter, secure, rotors back up, and take off).

I know most air ambulances in the US are nurse-led (why not paramedic?)
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Because by the very fact that something is being transported by air, you're looking at long transport times and/or more critically ill patients, that will require more advanced interventions typically beyond the scope of a paramedic. For example, in most states, paramedics can push meds, but they can't run a drip (continuous infusion). That requires a health professional license (RN, PA, or MD). Hence the need for a flight nurse. I'm sure there are others, such as expanded scope of practice with what meds they can use, etc. For example, in many parts of the US, paramedics are not allowed to utilize RSI (rapid sequence intubation, eg. etomidate & succs), and sometimes not even allowed medication-faciliated intubation (eg. giving versed to facilitate an intubation). Flight nurses can.

but I did see an EM programme at Cincinnati where the residents flew in their air ambulance to trauma calls....looked great!
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While the vast majority of air programs rely on prehospital personnel, there are quite a few programs that emphasize resident/fellow/attending physician participation, and even a few that specifically tailor to the subspeciality of flight physician & air critical care transport.

BTW, I sent ya a PM.
 
FDNewbie said:
Lucky you. Could you clarify what you mean by EM doctor? Cuz my understanding is that in Europe, the ER is called A&E (Accident & Emergency)

I read ya loud & clear. But I remember the documentary I watched online (can't find it now as luck would have it) mentioned how in the busy streets of London, even if a ground crew could - and often does - get there before the air team, their ground transport times were quite extended - to the tune of 40 minutes to so - to get to the nearest major Trauma Center. Hence why air is routinely dispatched, and while stabilization upon arrival was emphasized. As we all know, air takes quite a significant amount of time in it of itself (to find a landing zone, actually land, spin down, for you to get to the scene, transport back to the helicopter, secure, rotors back up, and take off).

Because by the very fact that something is being transported by air, you're looking at long transport times and/or more critically ill patients, that will require more advanced interventions typically beyond the scope of a paramedic. For example, in most states, paramedics can push meds, but they can't run a drip (continuous infusion). That requires a health professional license (RN, PA, or MD). Hence the need for a flight nurse. I'm sure there are others, such as expanded scope of practice with what meds they can use, etc. For example, in many parts of the US, paramedics are not allowed to utilize RSI (rapid sequence intubation, eg. etomidate & succs), and sometimes not even allowed medication-faciliated intubation (eg. giving versed to facilitate an intubation). Flight nurses can.

While the vast majority of air programs rely on prehospital personnel, there are quite a few programs that emphasize resident/fellow/attending physician participation, and even a few that specifically tailor to the subspeciality of flight physician & air critical care transport.

BTW, I sent ya a PM.
Click to expand...

Interesting stuff. In the UK Emergency Medicine is a recognised speciality in its own right just like the US. Google the "Royal College of Emergency Medicine" for links and syllabuses etc. The A&E is staffed by full time EM doctors. Trauma calls are run by A&E consultants/attendings with other members of the trauma team e.g. orthopaedic surgeons, general surgeons, anaesthetists. The orthopaedic surgeons do a combined trauma & orthopaedics service doing both elective and trauma cases.

It seems like flight nurses are a lot more skilled than ones in the UK, here nurses unless they have had specific training are not allowed to start drips whereas the paramedic license allows them to and something like 50 drugs. Not allowed to do RSIs either here.

PM sent.
 
I've done 2. One came in pretty much DOA, but we opened up his chest anyway. He'd been shot twice in the chest at close range, had a through-and-through cardiac wound and an aorta that had been blown to smithereens. Would have been nonsurvivable even if we'd done the case immediately after he'd been shot.

The second one was a guy who came in with a stab wound to the anterior chest; was basically up and ambulatory at the scene, but the police officer who responded "thought he looked pale" and brought him by squad car rather than wait for the ambulance to arrive. Good thing too cause he arrested in the trauma bay. We opened his chest, found cardiac tamponade, opened the pericardium and repaired the single RV stab wound with a couple pledgeted prolene sutures.

He went home POD #5. Coolest case of my residency, hands down

(but it reinforces the point that unless it's a penetrating trauma that basically loses vitals in front of you, most of these cases aren't salvageable)
 
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