First Thoracotomy

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SWWWWWEEETTTT. How ya doin man? Been a while.
 
Seriously...That was mean.
 
That's awesome. I did my first thoracotomy today. Having my hand on a person's heart freaks out my hell bus, man.
 
And you didnt send us any pictures? how dare you! 😀
 
Anuwolf said:
And you didnt send us any pictures? how dare you! 😀
Click to expand...

Since he is being rude and not sharing pictures, I'll post one of ours:

thoracotomy.jpg
 
mikecwru said:
Well, you already know how to do these, right? Don't you crack chests in between albuterol treatments?

mike
Click to expand...
No, I don't. I wasn't being sarcastic...I was actually congratulating him. Geez.....


NOTE: I apologize if I came across as rude, but I am exhausted since I've spent the past few days at the hospital with my critically ill grandfather (hence why I haven't been posting), so if I don't make myself clear that is part of the reasoning for it.
 
It was pretty cool... 23 yo guy got dropped off outside the ER w/ GSW to chest in the anterior box. Agonal respirations when the tech pulled him out of the car, full arrest upon hitting the trauma bay. Surgery got paged stat, but within 5 minutes, we had 3 2nd year EM residents in there and got him intubated, needle decompressed both sides of the chest, 2 cordis's placed, and I opened the L Hemithorax which poured out > 1000 cc blood and clot. Surgery made it down as I was picking up the pericardium, and we opened it up. He had a GSW through the apex and I stuck a foley in it while surgery cross clamped the aorta and explored for any other injuries or active bleeding. We sutured the heart and transfused 4 units prbcs and 6 L NS over the next 20 min. He actually had good contractility for about 10 min and we called up to the OR, but we never got a good pulse back, then he went into v-fib and we used intracardiac paddles and finally amio as a last ditch before calling it. That was probably the coolest thing I've done in medicine so far...

I wish I would have known how to connect IV tubing to the foley... I wanted to transfuse directly into the heart. I guess there's a CBI connector? Anybody know what I'm talking about???
 
waterski232002 said:
I wish I would have known how to connect IV tubing to the foley.
Click to expand...

You can take a tubing adapter (which looks like a double ended, clear version of the O2 "christmas trees") to connect the foley to a three-way stop-cock. Then connect the stop-cock to the IV tubing.



As for your experience, wow. Have the post-performance gitters passed?
 
EMT2RN2MD said:
You can take a tubing adapter (which looks like a double ended, clear version of the O2 "christmas trees") to connect the foley to a three-way stop-cock. Then connect the stop-cock to the IV tubing.



As for your experience, wow. Have the post-performance gitters passed?
Click to expand...


Those aren't jitters, that's the Hep C creeping into his bloodstream.

mike
 
That's awesome 😎

I heard the other day that one of the attendings where I work did one to show a resident. Double damn I wasn't there so I could watch with eager premed eyes. 😡
 
GeneralVeers said:
Since he is being rude and not sharing pictures, I'll post one of ours
Click to expand...

Wow pretty exhilarating! really like case 5 and Case2 😀

DropkickMurphy said:
NOTE: I apologize if I came across as rude, but I am exhausted since I've spent the past few days at the hospital with my critically ill grandfather (hence why I haven't been posting), so if I don't make myself clear that is part of the reasoning for it.
Click to expand...

I hope your grandfather gets better... My wishes goes to you and your family for his fullest recovery. I'll add him to my prayers list tonight 🙂
 
Boston's fantastic...except for the weather. Love working at BMC. Good crew to work with.
 
waterski232002 said:
It was pretty cool... 23 yo guy got dropped off outside the ER w/ GSW to chest in the anterior box. Agonal respirations when the tech pulled him out of the car, full arrest upon hitting the trauma bay. Surgery got paged stat, but within 5 minutes, we had 3 2nd year EM residents in there and got him intubated, needle decompressed both sides of the chest, 2 cordis's placed, and I opened the L Hemithorax which poured out > 1000 cc blood and clot. Surgery made it down as I was picking up the pericardium, and we opened it up. He had a GSW through the apex and I stuck a foley in it while surgery cross clamped the aorta and explored for any other injuries or active bleeding. We sutured the heart and transfused 4 units prbcs and 6 L NS over the next 20 min. He actually had good contractility for about 10 min and we called up to the OR, but we never got a good pulse back, then he went into v-fib and we used intracardiac paddles and finally amio as a last ditch before calling it. That was probably the coolest thing I've done in medicine so far...

I wish I would have known how to connect IV tubing to the foley... I wanted to transfuse directly into the heart. I guess there's a CBI connector? Anybody know what I'm talking about???
Click to expand...

i remember this one being presented at our M&M -- feels wierd to read about it again a month later on an internet forum
 
How common is it to have done at least one thoracotomy before the end of residency? Do most residency programs graduate docs with at least one throacotomy? Should students be looking for programs with enough penetrating trauma to get at least one thoracotomy?

How many of the upper levels here have done one?

ncc
 
GeneralVeers said:
Since he is being rude and not sharing pictures, I'll post one of ours:

thoracotomy.jpg
Click to expand...


OMG... did that in anatomy on Tuesday, but the patient had already been dead for several months. What's the recovery time after a procedure like that... a decade?
 
I did something very similar to the above just the other day. Doing a chest tube my staff said, get set-up, prep & drape, numb the area, make a small incision for the tube, then have the nurse come and get me. I must have gotten a little carried away...... oh the things we learn. Gosh I can't wait to match!?!? I think she wrote a letter for me...
 
boston said:
i remember this one being presented at our M&M -- feels wierd to read about it again a month later on an internet forum
Click to expand...

I'm curious what the comments were on the surgical side of things... Feel free to PM if you don't want to post. The heart got tense after such a massive transfusion and looking back we should have released the aortic cross clamp once we resuscitated the patient.

Did you hear about the Boerhaave's pt at M&M too?
 
I'm an undergrad and I volunteer in our ER. We did one last night on a blunt trauma patient (T boned). As someone who hasnt taken anatomy or seen that much in the grand scheme of things, it was one of the most amazing things I've seen. Unfortunately survival from blunt trauma is <2.5% or something like that (a 3rd year told me that), so cool stuff usually equates with death, unfortunately.

Its amazing to see the lungs working and the heart beating (or attempting to). And whacking the sternum just blew me away.
 
MWK said:
I'm an undergrad and I volunteer in our ER. We did one last night on a blunt trauma patient (T boned). As someone who hasnt taken anatomy or seen that much in the grand scheme of things, it was one of the most amazing things I've seen. Unfortunately survival from blunt trauma is <2.5% or something like that (a 3rd year told me that), so cool stuff usually equates with death, unfortunately.

Its amazing to see the lungs working and the heart beating (or attempting to). And whacking the sternum just blew me away.
Click to expand...


Unfortunately, thoracotomies are NEVER indicated for blunt trauma (ie your T-bone incident). Survival is NOT 2.5 percent it is effectively ZERO.

This must have been done for teaching purposes.

later
 
12R34Y said:
Unfortunately, thoracotomies are NEVER indicated for blunt trauma (ie your T-bone incident). Survival is NOT 2.5 percent it is effectively ZERO.

This must have been done for teaching purposes.

later
Click to expand...

Agreed, but we (EM and Trauma) did one the other day after the E-FAST showed hemopericardium with agonal activity. She had an LV rupture/. We opened the chest, sutured the LV, after filling it with O Neg, gave EPI/Atropine, OCM and CC the Aorta and the patient made it to the OR with a systolic of 120, ETCO2=38 .

I have to tell you this blew the trauma attending away as well, I was pretty shocked we got her back...that being said she did later die post op, but made it to the OR and out from her ED thoracotomy!👍

We had nurses who have been in the ED for 20 years, have seen the standard RA/RV stab make it up and out of the hospital, but never a blunt rupture..even thought her overall survival was zero, I would have done the same thing.


It did raise an interesting question in that we do not have open cardiac pacing pads....but after this case now we will! We obviously have paddles for open defibrillation, but you cannot pace with them.


Paul
 
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