Does the awesomeness wear off?

[DrDude]

Long story short, got to see a trauma surgeon do his thing. Patient brought in with thoracic trauma, surgeon came into the trauma bay, hit a slick thoracotomy, cardiac massage, back to sinus rhythm. Maybe you had to be there but it was definetly badass as it was going down. I know trauma surgery gets ragged on for whatever reasons, but to be able to do that seems so cool. So does it ever get old? True everything can get ordinary if you do it enough, but is your adrenaline still pumping when you run a trauma like that or does it become just another day at the office comparable with doing another H&P? I'm waffling between going into surgery and another specialty and have heard if you can imagine yourself doing any other specialty other than surgery then go into that specialty instead. Your insights would be helpful, especially from any trauma surgeons on board.

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[Blade28]

There's a good thread in this forum talking about the "daily grind" of surgery - Don't surgeons get tired of doing the same procedures over and over and over?.

But an ER thoracotomy? I've been in three, thought they were all thrilling. Of course the patients didn't make it. 🙁

So your patient lived? Just needed cardiac massage? No aortic cross-clamping? 😕

Are you reconsidering FP? 🙂

 

[DoctaJay]

Isn't the prognosis after a thoracotomy death like 98% of the time? Both the emergent thoracotomies I witnessed resulted in death, but the patient was probably already too far gone.

 

[opr8n]

Isn't the prognosis after a thoracotomy death like 98% of the time? Both the emergent thoracotomies I witnessed resulted in death, but the patient was probably already too far gone.

if done for the proper indication, its like 99% mortality
if done for the wrong indication its very close to 100%

 

[pseudoknot]

Isn't the prognosis after a thoracotomy death like 98% of the time? Both the emergent thoracotomies I witnessed resulted in death, but the patient was probably already too far gone.

Is death the prognosis, or the indication?

 

[njbmd]

Long story short, got to see a trauma surgeon do his thing. Patient brought in with thoracic trauma, surgeon came into the trauma bay, hit a slick thoracotomy, cardiac massage, back to sinus rhythm. Maybe you had to be there but it was definetly badass as it was going down. I know trauma surgery gets ragged on for whatever reasons, but to be able to do that seems so cool. So does it ever get old? True everything can get ordinary if you do it enough, but is your adrenaline still pumping when you run a trauma like that or does it become just another day at the office comparable with doing another H&P? I'm waffling between going into surgery and another specialty and have heard if you can imagine yourself doing any other specialty other than surgery then go into that specialty instead. Your insights would be helpful, especially from any trauma surgeons on board.

I had two out of ten (ED throcotomies) make it for me when I was in residency; both were GSWs to the chest. One of my best friends who is a Trauma surgeon, said that you need to love everything about this subspeciality not just the "sex and violence" in order to thrive here. ED thoracotomies are not the mainstay of the Trauma Surgeon (or General Surgeon who does trauma work) for that matter. He spends a great deal of time doing burn surgery and general surgery/surgical critical care in addition to his trauma work after completing a two-year Trauma surgery fellowship and accepting a position in an inner-city Level I Trauma center.

The other thing to consider is that there are not that many trauma centers in this country where you will be getting loads ofthe types of trauma that will tend to yield ED thoracotomies. Most trauma is blunt these days with relatively conservative management. This might not appeal to you.

Still, General Surgery offers plenty of variety and challenge to folks who love working with their hands and thinking on their feet. Once in awhile, it is punctuated with "cracking a chest" and other heroic maneuvers but day in and day out this specialty is operating and take care of the needs of your patients with surgical techniques.

 

[Castro Viejo]

Is death the prognosis, or the indication?

The only thing death is an indication for is transfer to the ECU.

 

[Castro Viejo]

Long story short, got to see a trauma surgeon do his thing. Patient brought in with thoracic trauma, surgeon came into the trauma bay, hit a slick thoracotomy, cardiac massage, back to sinus rhythm. Maybe you had to be there but it was definetly badass as it was going down. I know trauma surgery gets ragged on for whatever reasons, but to be able to do that seems so cool. So does it ever get old? True everything can get ordinary if you do it enough, but is your adrenaline still pumping when you run a trauma like that or does it become just another day at the office comparable with doing another H&P? I'm waffling between going into surgery and another specialty and have heard if you can imagine yourself doing any other specialty other than surgery then go into that specialty instead. Your insights would be helpful, especially from any trauma surgeons on board.

Your patient survived with just cardiac massage? I'm also a little surprised by this. Hmmm... Methinks the patient might have even survived with a simple pericardiocentesis. Oops. 🙂 But you neve really know.

As NJBMD wrote, doing ED thoracotomies isn't the bread and butter of Trauma Sugeons or General Surgeons. Most trauma centers aren't going to see this kind of thing on a regular basis, so it doesn't particularly get old. It's actually kind of exciting for everyone involved, especially if a patient makes it (but that's pretty rare).

If you're considering life as a Trauma Surgeon, you need to really look into what they do in between the chest cracking and exciting stuff. There's a lot of pain that goes along with Trauma, especially if you're doing a lot of Surgical Critical Care and running a SICU. There's also a lot of pain that goes along with the babysitting.

But these are my observations of Trauma. I think it's crazy exciting, but could never do it day in-day out.

 

[Blade28]

Too much non-operative work and off-service babysitting (Ortho and NSGY) for me to consider Trauma.

 

[Winged Scapula]

Imagine this scenario:

you are working at a hospital with very little penetrating trauma. You never witness a thoracotomy or have a chance to do one. Your life is day in and day out in the CT scanner, babysitting other's patients, dealing with social workers, putting a some PETs, PEGs, medical problems on your patients and endless SICU and floor rounds.

Sound appealing? If so, then go into Trauma Surgery.

As others have noted, the thrill you experienced is not very common except at the most dangerous and busy trauma centers. I never once saw an ED thoracotomy, nor a patient would would have needed one during my residency. Perhaps if I had I would have thought differently about the specialty, although frankly, my experience (as detailed above) is FAR more common that what you have described.

 

[opr8n]

Too much non-operative work and off-service babysitting (Ortho and NSGY) for me to consider Trauma.

couldnt have said it better myself

ive done 4 months of trauma (2 floor, 2 STICU) so far in two years of residency
2 more in medical school
and its not what I want to do the rest of my life for sure

 

[ExtraCrispy]

As in any specialty, you also have to consider the patient population. The patients who roll in during a trauma are often people who were drunk, high on drugs, or committing a crime when they got hurt, or they are the victims of the aforementioned crimes. It can get depressing after a while.

Case in point: The one trauma thoracotomy that I know of in the ED this year was a success. Pt in w/ GSW to chest, coded in the bay, they cracked him open, and they stopped the bleeding from a pulmonary venous tear from which he was hemorrhaging. He was awake, extubated and talking the next day.

Amazing, right? Yes, until you consider that the guy was shot running away from the police, after he had attacked his mother and stabbed her to death (because she wouldn't pay his taxes for him).

Confronted all the time with the awful things that people do to each other, you lose some of the thrill of those "great" trauma moments.

 

[Castro Viejo]

Confronted all the time with the awful things that people do to each other, you lose some of the thrill of those "great" trauma moments.

That's why I almost never want to know the background story to how someone ended up on the operating table after some wicked trauma.

All I need to know are the relevant facts that will aid me in understanding what's wrong and how to fix it. I hate knowing that, "Oh, well, this guy shot eight kids execution style in a Kindegarten classroom and the Police unloaded their guns on his a$$." It clouds my judgement, I think, and all of a sudden something that could be better becomes just good enough.

 

[opr8n]

Confronted all the time with the awful things that people do to each other, you lose some of the thrill of those "great" trauma moments.

one night i was on trauma call
2 traumas came in at once
one guy shot a cop
the cop shot back

the chief gave me a choice of which trauma i wanted to run
which do you think i chose??

the bad thing about trauam is that you treat scumbags 80% of the time who dont care what you do for them


BUT on a positive note, i hada guy running from the cops (in his car), and he got into an accident with a lightpole, the pole won. I took care of him in the ICU for 45 days then i went off service and came back on the floor 2 months later and discharged him. He told me he found god in the hospital and was going to change his life and do something productive for society (once he got out of jail of course)
maybe he will, maybe he wont??

 

[GregsAnatomy]

I was thrilled to see an ED thoracotomy my first night of call at a major inner-city Level 1 trauma center. The unfortunate patient was a clerk in a store that was robbed by two men who shot him, took the cash drawer, and took the tapes from the video surveillance. He sustained a GSW to the LLQ but paramedics lost vital signs en route and patient arrived at trauma bay with 0 pulse. ED thoracotomy was performed with aortic cross-clamp and open cardiac massage and we got him back. We then fixed his iliac blow-out and some intestinal injury in the OR. When I left the trauma service he was awake and alert although not speaking--but still amazing to know that we were able to resuscitate a person from next-to-nothing.

Unfortunately, a case like that is more the exception than the norm in trauma surgery. But if it was...I'd definitely say sign me up!!! 👍

 

[redbeans]

I saw my first EC thoracotomy today!! And the patient is still alive 12 hours later (fingers crossed)! He came in pulseless in the field, GSW to chest and the bullet just fell out when his chest was cracked and pericardium opened. Of course he was coagulopathic all through the sewing of his LV after he got up to the OR, and then had to be taken back after an hour, but now he's stable. Amazing. Bloody, amazing.

 

[Castro Viejo]

I was thrilled to see an ED thoracotomy my first night of call at a major inner-city Level 1 trauma center. The unfortunate patient was a clerk in a store that was robbed by two men who shot him, took the cash drawer, and took the tapes from the video surveillance. He sustained a GSW to the LLQ but paramedics lost vital signs en route and patient arrived at trauma bay with 0 pulse. ED thoracotomy was performed with aortic cross-clamp and open cardiac massage and we got him back. We then fixed his iliac blow-out and some intestinal injury in the OR. When I left the trauma service he was awake and alert although not speaking--but still amazing to know that we were able to resuscitate a person from next-to-nothing.

Uhm, an ED thoracotomy for a guy who lost his vital signs from a solitary gun shot wound to the LLQ? And the vitals were lost on the bus? Was there any kind of injury to the patient's chest?

That's a bit of a cowboy move in my book. There's no clear indication for the thoracotomy except for total and complete desperation. The Trauma man could've done the same thing by lapping the poor bastard in the ED and squeezing on the aorta. I mean, you're gonna open the belly anyway, so you might as well crack the belly and leave the chest alone.

Was it a Trauma Surgeon who cracked the chest or an over-zealous ED guy? They tend to do some bone-headed things like that. We had an ED guy who cracked a chest for a patient he suspected had a ruptured AAA. He turned out to be wrong. Patient lost his vitals from massive MI. Either way, it was the wrong move.

 

[Castro Viejo]

I saw my first EC thoracotomy today!! And the patient is still alive 12 hours later (fingers crossed)! He came in pulseless in the field, GSW to chest and the bullet just fell out when his chest was cracked and pericardium opened. Of course he was coagulopathic all through the sewing of his LV after he got up to the OR, and then had to be taken back after an hour, but now he's stable. Amazing. Bloody, amazing.

An ED thoracotomy that was indicated and saved the patient. Good stuff.

So what did your guys do when they found the hole in the heart after opening the pericardium?

 

[Castro Viejo]

From Trauma.org.

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

 

[GregsAnatomy]

Uhm, an ED thoracotomy for a guy who lost his vital signs from a solitary gun shot wound to the LLQ? And the vitals were lost on the bus? Was there any kind of injury to the patient's chest?

That's a bit of a cowboy move in my book. There's no clear indication for the thoracotomy except for total and complete desperation. The Trauma man could've done the same thing by lapping the poor bastard in the ED and squeezing on the aorta. I mean, you're gonna open the belly anyway, so you might as well crack the belly and leave the chest alone.

Was it a Trauma Surgeon who cracked the chest or an over-zealous ED guy? They tend to do some bone-headed things like that. We had an ED guy who cracked a chest for a patient he suspected had a ruptured AAA. He turned out to be wrong. Patient lost his vitals from massive MI. Either way, it was the wrong move.

Agreed. Wish I could remember more details about the case but the patient's major injury was a blowout of the left iliac. Although, like you say above, ED thoracotomy was relatively indicated.

It was the trauma surgeon's move in this case, and I believe the institution is involved in a study of ED thoracotomy indication for loss of vitals en-route.

 

[redbeans]

An ED thoracotomy that was indicated and saved the patient. Good stuff.

So what did your guys do when they found the hole in the heart after opening the pericardium?

OK so he was still in asystole, they were massaging the heart and injected the muscle with epinephrine. I think it did restart beating at this point. To plug the hole they tried a balloon like a foley catheter, but the hole was too big and it came right out. So the chief just clamped the heart closed and wheeled him to the OR. There they packed and explored, sewed the defect, were about to try Argon. They left chest tubes in and the chest wall only clamped shut before sending to the ICU to stabilize. An hour later the chest tubes were pouring out blood, he'd popped stitches and had to be taken back. After resewing the ventricle and some lung ligation, he stabilized quickly and is chilling in the ICU.

I'm going to have dreams about this for the next week.