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DO EM RESIDENCIES

Discussion in 'Emergency Medicine' started by spunkydoc, Jan 18, 2001.

  1. spunkydoc

    spunkydoc Senior Member

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    Anyone out there very familiar with the St. Barnabas Bronx EM program who would care to share the inside scoop? I would be very appreciative for any info ASAP!!

    Thanks
     
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  3. rtk

    rtk Member

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    I did a month rotation as a 4th year med student in ER at St Barnabas. It was a great month rotation... I did a ton of procedures as a student and the ER was always packed. Plently of trauma: GSW's and stabbings, only one MVA in one month though. Tons of HIV/AIDs OI's, drug overdoses.

    Barnabas is smack-dab in the Bronx, rough neighborhood... but Little Italy is close by and Fordam University is close. After being there for a month, I was sure I didn't want to spend four years there... But I'm from the midwest and missed some of the finer things in life; I.E: grass, trees and friendly people.
     
  4. spunkydoc

    spunkydoc Senior Member

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    RTK-THANKS FOR THE RESPONSE...MIND EMAILING ME TO TALK MORE? I AM WELL AWARE OF THE LOCALE--IN FACT I WANT A DIE HARD COUNTY PROGRAM AS I LOVE THE INNER CITY AND ALSO WANT THAT TYPE OF TRAINING..I AM MORE CONCERNED WITH THE INTERACTIONS BETWEEN FACULTY MEMBERS, FACULTY AND RESIDENTS, THE QUALITY OF THE FACILITY, THE CAMRADERIE BETWEEN RESIDENTS, MOONLIGHTING OPTIONS, THE INSIDE STUFF...I AM POSITIVE THAT IT IS A SOLID RESIDENCY ACADEMICALLY..I AM WORRIED ABOUT THE REST...BTW, WHERE DID YOU LIVE WHEN YOU WERE UP THERE? DID YOU NOT FIND THE STAFF/EMPLOYEES FRIENDLY? THE POPULATION IS BOUND TO BE UNFRIENDLY AT TIMES, BUT WHAT ABOUT THE WORK ENVIRONMENT?

    THANKS
     
  5. Detroit Rock City

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    I read the posts by RTK and I musyt say that I disagree.
    First- I was born and raised in Brooklyn NY USA. I recently moved to Detroit. I think New Yorkers are some of the nicest people around. I compare newyorkers to the french. If you make an attempt to understand them they wil bend over backwards for you. Of course this isn't green acres here, things move a bit faster than in kansas city.
    Second. Little Italy is NOWHERE near the bronx. nowhere!
    Third- when you consider your residency training there are any factors that you need to take into account. For me the most important was to train in an innercity hospital. My logic is that if I can work in a zoo for three years and survive, then I'll be well equipped to work anywhere in this country. I have talked to people who train at other programs and rotate through our hospital for their trauma surg and ed months. They feel that their training is adequate. They do 2 months of trauma em at my hospital, I do 3 years.
    Fourth-- Many say that all trauma is the same and that you run one trauma code, you run them all. The only thing I can say is that practice makes perfect. How many thoracotomies have you seen? Come to Detroit!
    The only caveat is that you need to be happy where you train. You are going to be there a while and probably not know many people. Good luck with whichever program you chose ( can chooses you)
    DRC
     
  6. jdaasbo

    jdaasbo Senior Member

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    Wow,

    Little Italy is in Manhattan

    The Bronx is separated from Manhattan by a body of water (and some bridges and tunnels).

    Detroit:


    Just a question, but exactly how many patients who you saw have emergent thoracotomies actually SURVIVED?

    My understanding is that this number is well under one percent.
     
  7. Detroit Rock City

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    Last time I checked, zero had survived the procedure, but that is not the point. The point is that, in the unfortunate instance that I should have to perform the procedure, I will have a clue as to what I'm doing (ie the right way to cross-clamp.
    Residency is all about training, not loafing. I see people come for interviews and they say that other programs have less hours and less volume, and that they would prefer those programs. If I ever should need the care of an EM physician I pray that he trained in the trenches and not in a country club.
    Just my opinion
     
  8. rtk

    rtk Member

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    Can't believe I'm getting bashed about the little Italy thing... St. Barnabas is located off Fordam Rd and Aurthur avenue in the Bronx. Perhaps the area of the Bronx in which I stayed isn't the 'official' little Italy of NYC. However, that is what it was referred to by the residents and staff at St. Baranabas. "A Bronx Tale", a movie about the mafia and Italian emigrants growing up in NYC was filmed there. Ann and Tony's (an italian restuarant) was two blocks away and was a central point of the movie. (doesn't prove that this area is little Italy, but it's certainly the Italian area of the Bronx...)

    Alot was inferrred about my 4 line post... I stated that there was a bunch of pathology in the ER at St. Barnabas, however, somewhat weak in MVA trauma... Detroit, not sure I agree that if you train in the inner city, you'll be ready for anything. Not all traumas are the same. Caring for a GSW pt is different than an MVA pt. How much Ag trauma do you see in the ED in Detroit? (eg: Anhydrous spills). My point is, your never gonna see everything that'll come your way in practice, but try to increase your chances by training in a program that will be similar to what you anticipate doing when you finish residency. If you're not gonna practice in a place like St Barnabas when you finish residency (which sees tons of HIV, end-stage disease, drug OD's, street violence) but is weak on the conventional trauma of the ED (re: MVA trauma) then you'd be better off somewhere where you will get plenty of exposure to the types of emergent cases you'll see in practice...

    Detroit, last I checked, Kansas City wasn't green acres. There's indoor plumbin' N 'lectricity. Guess you big Detroit city types wouldn't understand us small town country folk. Thing's must be bunches dif'rent down here in this big midwestern town than up there in that big midwestern town. Someday we hope to be real 'city-fied' like ya'll.

     
  9. jdaasbo

    jdaasbo Senior Member

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    Detroit:

    But if everyone who has this procedure done dies, then what is the point of teaching a procedure that has no medical benefit (to the patient)?

    I listened to this same debate between a group of trauma surgeons and the chair of the surgery dept at an M&M report. The later's opinion was exactly the one I voiced above. When he asked the trauma dept if any of them could remember saving apatient by doig this there was a long pause and then one guy confessed that 15 years ago at Kings County he had seen one that saved the patient (but then he later died in the SICU from infection.)

    My point is that perhaps emergent thoracotomies are not evidence based medicine.

    What do you think?



    ------------------
    Johan Aasbo
    M3 CCOM
     
  10. Detroit Rock City

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    Johan,
    I agree that the procedure is usually a total waste of time. However, until someone comes up with somehting better, I guess we have no other alternative except sit back and watch em' croak. I didn't sign up to sit back and do nothing, so I'll take my chances, no matter how slim they are.
    RTK,
    If you read my posts you would see that I'm not from Detroit but from NYC. So you see a couple of italians on a street corner and you think that you are in little italy. Detroit is the home of the car, and we have buttloads of farms within 20-30 miles of the city. To me, it sounds just like KC. Funny thing is we have a resident here from KC, says that the 2 are not similar in the least. But I guess you wouldn't know that, too busy tipping cows!!?!?!?
     
  11. turtleboard

    turtleboard SDN Advisor

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    Each of New York City's five boroughs is home to different ethnic groups, and each borough has "ethnic neighborhoods." It's no surprise that the Bronx, long known for its history of urban decay in the past 30 years, has a visible Italian population because more than 30 years ago the Bronx was populated mainly by Jewish, Irish, and Italian immigrants. Demographics change and now most people outside New York know the Bronx as mainly a black and Hispanic city -- but surprise, some of the older immigrants are still there and still maintain their ethnic neighborhoods. So it's quite likely that there is a "Little Italy" in the Bronx.

    BUT the name "Little Italy," in the minds of most New Yorkers, reminds them of the Italian neighborhood next to Chinatown on Manhattan Island (or New York County), and NOT the Bronx Italian neighborhood. Brooklyn has an Italian neighborhood in the Bensonhurst section, but we don't call it "Little Italy." There's also a "Chinatown" in Queens and one in Brooklyn, but when I say "Chinatown," most New Yorkers will think of Manhattan's and not one of the outer-boroughs.

    Why is survival from an emergent thoracotomy so low?


    Tim W. of N.Y.C.
     
  12. jdaasbo

    jdaasbo Senior Member

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    Detroit (Paul Stanley?),

    The assumption is made in your argument that doing "something" is better than doing "nothing." I don't agree with this principle.

    You speak of what you "signed up to do" as a physician rather than what perhaps the patient would want. I think that one of our cheif jobs as a doctor is to relieve suffering to the best of our ability (within the constraints of the hippocratic oath ofcourse). Sometimes I feel that modern medicine and medical training overlooks this in favor of trying to do anything and everything to save the patient. I do believe in dying with dignity.

    What I am saying perhaps is that since we know that with certain types of injury, in certain types of situations, certain people have a virtually nill chance of surving an ED thoracotomy (see my post in "Everyone" section), we should be more selective in choosing who gets an ED thoractomy. I am not against ED thoracotomies in all circumstances. That said, I have witnessed 70+ year old women undergo ED thoracotomies post MVC. This in my opinion is NOT dying with dignity. At that age, speaking for myself only ofcourse, I would not want to be gutted like a fish for the (far) less than one percent chance of survival. I am in favor of more carefully evaluating the likelihood of survival in individual people in individual circumstances before performing an ED thoractomy.

    Death is something that happens to us all eventually. Perhaps we as physicians should spend less time trying to heroically prevent our patients from achieving this end and more time improving quality of life while they are still alive, even for the last few minutes of life.



    ------------------
    Johan Aasbo
    M3 CCOM
     
  13. Detroit Rock City

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    Johan,
    I don't know where you have seen a 70 year old lady s/p mvc get her chest cracked but there is a criteria that must be met in order for the procedure to even be considered. It is my understanding that the pt must be s/p penetrating trauma to the chest or abdomen with loss of vitals en route to the hospital or while in the hospital. A pt s/p mvc clearly would not qualify. I agree that we should take the best interests of the pt's into account, but since I doubt they wanted to be shot, stabbed or impaled, I think they would appreciate the effort, no matter the outcome.
    DRC
     
  14. jdaasbo

    jdaasbo Senior Member

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    Well, that is the truth. I was present for both of these. Both of them were blunt trauma. One of them was stable when she arrived. She crashed down in CT and we brought her back up to the trauma bay, where we worked on her for about 10 minutes before we then asked the family how far they wanted to go. They said all the way, so she got a thoracotomy. I sewed her up afterwards.

    I know for a fact, not only from experience, but also from reading that blunt trauma can definately be an indication for thoracotomy. The surgeon (as all the trauma docs there are) was fellowship trained in trauma surgery. Whatever protocols there were, she must have met them I guess. As with all trauma's at this hospital the ED's role is limited to airway management until the anesthesia resident on call for trauma gets there (at which point they leave the room).



    ------------------
    Johan Aasbo
    M3 CCOM
     
  15. Detroit Rock City

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    Johan,
    I have 2 things for you.
    1) If that is true, and the EM doc's just support airway until anesthesiology shows up then that is a hospital that I don't think deserves an EM residency. Where I train we switch off with the trauma docs because we both know, more likley then not that the EM doc will be the one to intervene. (Of all hospitals in the US only 8% are level I)
    2) I think you have read wrong, but I'm not sure. I'm studying for inservice now and blunt trauma is not an indication for thoracotomy, at least that is what my understanding is. Where are you reading otherwise?
     
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  17. Detroit Rock City

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    Johan,
    I stand corrected. I just looked and there is 1 indication for blunt trauma that can result in ERT, but this requies a set of criteria be met that is rather extensive and is successful in only 1-2 % of cases. The source I found also states that ERT has apositive outcome in approx 50% of penetrating chest trauma.
    DRC
    P.S. Obvious limitations are they don't list what they mean by positive outcomes and the don't list study size.
    Regardless, I'll continue to train on how to do the procedure and if criteria are met would not hesitate to do it. I think that attempting to save the patient is what is the patient's best interest reagrdless of any statistical data you can find.
     
  18. Detroit Rock City

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    One more thing:
    Any pt who has received CPR for 10 min while intubated or 5 min without intubation (Your lady in CT) is ABSOLUTELY CONTRAINDICATED for emergent thoracotomy, no matter the cause. I don't question your statement of facts, but I do question the quality of your educational experience while on that rotation, if that is in fact what actually transpired. Do you remember what the outcome of the M&M conference was? Did they say it was a valid procedure, warranted under the circumstances?
     
  19. jdaasbo

    jdaasbo Senior Member

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    Detroit,

    Let me quote:

    Survival after emergency department thoracotomy: review of published data from the past 25 years.

    Rhee PM - J Am Coll Surg - 2000 Mar; 190(3): 288-98
    From NIH/NLM MEDLINE, HealthSTAR


    NLM Citation ID:
    20166619

    "...Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. RESULTS: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries.

    When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries.


    If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%..."


    Perhaps this study is out of date or incomplete in some respect, but according to this data the survival rates are nowhere near 50% for any category.

    Now about this rotation site. The site is the second busiest Level 1 trauma in downtown chicago. It is an academic teaching hospital and home to one of the largest if not the largest general surgery program in the state. It also has a trauma/critical care surgery fellowship. The trauma attending on call the night in question is two years out of this fellowship. In addition the current trauma fellow was on that night.

    Now, as far as the quality of the EM residency there let me say this. I don't know a whole lot about how EM programs stack up, but let me just say that this one is considered to be one of the best if not the best in the city. That said, it is true that the residents there spend time between three hospitals, and get their trauma experience while 1) on the trauma service at that hospital or 2) on EM at another level one trauma in the burbs.

    I have absolutely no doubt that my surgery experience there was world class and that trauma surgeons there are among the best in Chicago. I know a second rate rotation when I am on one, and this was not it.

    So, if the lady in question being "down" for what was probably under (but certainly felt like) ten minutes before attempting thoracotomy was an ABSOLUTE CONTRAINDICATION, in your words, then i question your source.

    During M&M there was never any question of the procedure being valid or not. In fact, the chairman of the trauma department commented (and I specificaly remember this) that he could not realisticaly attribute the negative outcome to any facet of the patient's management. The case was presented in my point of view because it was shocking to have such an outcome in a patient who was early on in the management quite stable.


    this reminds me:

    "Any pt who has received CPR for 10 min while intubated or 5 min without intubation (Your lady in CT) is ABSOLUTELY CONTRAINDICATED for emergent thoracotomy, no matter the cause"

    I was involved in two other thoracotomy cases which clearly according to the above statement were contraindicated. I cannot believe that an entire department of seven FACS trauma surgeons are regularly doing ABSOLUTELY CONTRAINDICATED thoracotomies (as your statement would lead me to conclude.)

    Sorry, but I respectfully disagree with you.



    ------------------
    Johan Aasbo
    M3 CCOM
     
  20. jdaasbo

    jdaasbo Senior Member

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    Or perhaps there is a huge discrepancy in the literature. Can you quote your source?


    ------------------
    Johan Aasbo
    M3 CCOM
     
  21. jdaasbo

    jdaasbo Senior Member

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    I hate to beat a dying horse.


    this is from:

    Surgical Clinics of North America
    Volume 79 ? Number 6 ? December 1999
    Copyright ? 1999 W. B. Saunders Company

    1417
    TRAUMA CARE IN THE NEW MILLENNIUM

    ADVANCES IN THE DIAGNOSIS AND TREATMENT OF THORACIC TRAUMA

    David V. Feliciano 1 2 MD
    Grace S. Rozycki 1 3 MD RDMS

    1 Department of Surgery, Emory University School of Medicine (DVF, GSR);
    2 Department of Surgery (DVF)
    3 Division of Trauma/Surgical Critical Care (GSR), Grady Memorial Hospital, Atlanta, Georgia


    "Current Role of Emergency Center Thoracotomy
    Following the publication of the paper by Blalock and Ravitch in 1943 [9] advocating nonoperative treatment for cardiac tamponade, there was presumably

    some decrease in the number of emergency thoracotomies in urban trauma centers. The rapid proliferation of penetrating thoracic wounds in such centers over the next 10 years quickly led to a more aggressive approach using emergency center thoracotomy. [7]
    The current strong indications for emergency center thoracotomy are listed as follows [25] :
    1. Penetrating thoracic wound with agonal state or recent cardiac arrest on arrival, deterioration or cardiac arrest after care has been started in the emergency center, or uncontrolled hemorrhage from the thoracic inlet or out of a thoracostomy tube
    2. Suspected subclavian vessel injury with intrapleural exsanguination
    3. Need for open cardiac massage or occlusion of the descending thoracic aorta before laparotomy in the operating room
    4. Need for open cardiac massage or occlusion of the descending thoracic aorta when countershock or closed chest cardiac massage is ineffective (i.e., cardiopulmonary arrest)
    Relative indications would include a recent cardiac arrest and associated flail chest, multiple blunt trauma, pregnancy or an abnormality of the chest wall, or the need for fluid infusion by an intracardiac route. Strong contraindications to use of the technique include penetrating trauma with no signs of life in the field and blunt trauma with no signs of life on arrival in the emergency center. [17]"


    The old lady in question was a recent cardiac arrest who had multiple blunt traumas. There is no reference to time in the above article.



    ------------------
    Johan Aasbo
    M3 CCOM
     
  22. jdaasbo

    jdaasbo Senior Member

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    here is another one:

    [Blunt thoracic injury]
    Miura H - Jpn J Thorac Cardiovasc Surg - 1998 Jun; 46(6): 556-60
    From NIH/NLM MEDLINE, HealthSTAR


    NLM Citation ID:
    98386847

    Full Source Title:
    Japanese Journal of Thoracic and Cardiovascular Surgery

    Publication Type:
    Journal Article

    Language:
    Japanese

    Author Affiliation:
    Department of Thoracic Surgery, Hachioji Medical Center of Tokyo Medical College, Japan.

    Authors:
    Miura H; Taira O; Hiraguri S; Uchida O; Hagiwara M; Ikeda T; Kato H

    Abstract:
    Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.

    -----
    These guys had some pretty good results, albeit with a nonsignifcant N number.

    Clearly there must be more than one indication for ED thoracomy s/p blunt chest trauma. I make special note of the last line.

    ------------------
    Johan Aasbo
    M3 CCOM
     
  23. Detroit Rock City

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    Johan,
    I did a search on yahoo, and it was the 1st or 2nd citation thaqt I saw. Dont remember the exact source.
    Just talked to one of my friends who is a trauma surg resident. I showed him this site. He is of the opinion that the decision needs to be based on an individual basis. I think that we are in agreement. I fear that the reason that your program performs so many of these "useless" procedures as you call them is to teach their residents. I think many other trauma doc's aside the chicago 7 that you refer to would never do such a procedure on someone so old.
    Off point: Are you planning to do a surgery residency?
     
  24. Detroit Rock City

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    www.wits.ac.za/trauma/DSTC4.htm
    I also found this comical www.llu.edu
    It is Loma Linda's EM residency page
    they show pictures of their EM residents doing a thoracotomy.
    I pray there was a trauma surgeon in the backround!
     
  25. gentges

    gentges New Member

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    (DRC, etc)
    You guys are fighting too much. To clear up the Little Italy thing, Dr. Schiowitz, D.O., the Dean of NYCOM, came to our school (OSU-COM) recently, and I got to speak with him. There is definitely an area adjacent to the hospital that he identifies as Little Italy. I have been to Manhattan and know that the 'offical' Little Italy is SE of Central Park. BTW, Dr. Shiowitz was the nicest old man, and has pretty much solidified my decision to go to NYCOM/St. Barnabas for my EM residency.
    RTK,
    If you read my posts you would see that I'm not from Detroit but from NYC. So you see a couple of italians on a street corner and you think that you are in little italy. Detroit is the home of the car, and we have buttloads of farms within 20-30 miles of the city. To me, it sounds just like KC. Funny thing is we have a resident here from KC, says that the 2 are not similar in the least. But I guess you wouldn't know that, too busy tipping cows!!?!?!?[/B][/QUOTE]

     
  26. jdaasbo

    jdaasbo Senior Member

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    Detroit,

    I am going to do a medicine residency and then specialize (in cardiology?)

     
  27. Z

    Z

    I must admit, this has been an interesting discussion regarding the usefulness of ER thoracotomies. I was also gald to see that someone finally began to look at the data available on the subject. Since I am a surgical resident in one of the busiest trauma centers in the country, I thought I might throw in my two cents worth.

    Several points need to be emphasized. There are some clear cut things in medicine and surgery, however, the use of emergency department thoracotomy is not one of them. Usually when there are multiple studies over many years with widely varying results one can be sure there will be no clear answer. However, as the review by Rhee et al. indicates, there may be a way to break the patients down. Clearly, mechanism of injury and signs of life are the two key factors across the board for all studies involved. The person with the highest chance of walking out of the hospital after an ED thoracotomy is one who dies in the ED and has suffered a stab wound to the chest. This low energy mechanism makes repair of this type of injury much easier. The least likely person to survive is one who suffered blunt trauma, no matter the mechanism, who had signs of life in the field but died close to the hospital. The fact that patients suffering blunt trauma may have many more reasons to die (pelvic bleeding, severe head injury, etc) other than an isolated thoracic injury amenable to ED thoracotomy is the reason ED thoracotomy is less effective in this patient population. A recent study published in the Journal of Trauma by Tyburski et al from Wayne State University at the Detroit Receiving Hospital brings out another point. Of the 152 patients with an ED thoracotomy, 93 suffered gunshot wounds and none survived to walk out of the hospital. Of the remaining 59 patients, all of whom had stab wounds, 20% survived. Gunshot wounds are a high energy penetrating injury. This combination is likely to be lethal in a shot to the heart where the myocardium can suffer a severe contusion as well as penetration resulting in unsalvagable arrhythmias.
    So, when discussing this subject it is important to stratify patients based on the mechanism of injury. Based on these and other data the indications for ED thoracotomy at our institution currently are:

    1. Penetrating injury to the chest (either gunshot or stab) with signs of life within 5 minutes of arrival to the ED.

    2. Blunt trauma with signs of life on arrival to the hospital and in whom cardiac rupture is suspected (either by signs of tamponade on physical exam or by ultrasound). In 99.9% of other cases, blunt trauma does not warrant an ED thoracotomy.

    Two other brief points. When examining the literature one must look at it critically. With regard to that, in the reference sited from the Japanes journal of Thoraic and Cardiiovascular Surgery, the thoracotomies were performed in the OR not in the ED. This is much different. The patients were in shock on arrival and not yet dead. Second, there are cases in which the performance of an ED thoracotomy is not likely to result in a good outcome, however, it is undertaken anyway, especially at a teaching institution so that residents may learn the procedure. This, in my opinion, is justified since without practice when a patient arrives who is likely to survive an ED thoracotomy, he or she may die as a result of the ignorance to the procedure of their doctor.
     

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