Now that the job market is collapsing, can we have some real discussion on the best residency programs?

[deleted547339]

Anyone frequently admitting patients with cirrhosis should be performing paras. AKI, altered mental status, fever, abdominal pain - all would necessitate a paracentesis to inform management. A thoracentesis, on the other hand...

As far as the pericardiocentesis - I have done one in a traumatic arrest scenario in the field. I don't think having done this procedure multiple times should be included in anyone's metrics for a "solid program".

Traumatic arrest = open chest.

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[AlmostAnMD]

Or just know what the tip of your needle looks like on ultrasound.

The guy that did the LP and got sued for meningitis knew where his needle was. Remember that thread?

Every time you put a needle in a very protected space and it's not 100% life or death necessary to do so, don't do it.

This is the difference between docs that take risk management and docs that don't.

You can do 50 invasive procedures and they all go great. #51 gets an infection? Guess who just lost that lawsuit?

 

[deleted547339]

Will they live 10 more minutes???

Yes

otherwise

no

Dunno, only would have known that if I had waited 10 minutes. And if a patient codes from tampon are, they don’t come back. So, sir, I’m sorry things went bad, but I had to do something to try to help.

 

[deleted547339]

The guy that did the LP and got sued for meningitis knew where his needle was. Remember that thread?

Every time you put a needle in a very protected space and it's not 100% life or death necessary to do so, don't do it.

This is the difference between docs that take risk management and docs that don't.

You can do 50 invasive procedures and they all go great. #51 gets an infection? Guess who just lost that lawsuit?

So your afraid of doing a pericardiocentesis because risk of iatrogenic infective pericarditis.....seems....far fetched.

 

[AlmostAnMD]

So your afraid of doing a pericardiocentesis because risk of iatrogenic infective pericarditis.....seems....far fetched.

I do procedures when I need to do them.

I haven't been sued.

Beyond that, do a pericardiocentesis every shift the rest of your life, regardless of indication. It's your career, not mine.

 

[southerndoc]

Traumatic arrest = open chest.

Traumatic arrest = dead.

 

[clibby]

From a risk management standpoint, if you're doing a thoracentesis, paracentesis or pericardiocentesis you better be prepared to write a huge check if anything goes wrong.

Lawyer:
You're at a major tertiary care center?

You:
Yes

Lawyer
You have IR/interventional cards available?

You:
Yes

Lawyer:
Was the patient hemodynamically unstable and unable to wait for a specialist?

You:
No

Lawyer:
So Doctor, why did you do the procedure?

Nothing you say matters, you just write the check. I think in significant hemodynamic situations/codes or with some leeway to podunk ED's situated between cows you might get some sympathy but a jury will hang you dry if you had an interventionalist upstairs sleeping while you felt badass enough to stick a needle in someone's heart and a mistake was made--even if the specialist would have made the same mistake!

For reference, with appropriate specialists precepting in residency I did
2 paracentesis
1 thoracentesis
2 pericardiocentesis

As an attending I've done only one of those, a pericardiocentesis in a code caused by massive tamponade. That, I think, is the only time we are allowed to stick a needle in a heart and if you're doing that twice per shift you're unlucky or not doing it for the right reasons.

Thoras? I get not doing those. If they need it drained, they need a chest tube.

Pericardiocentesis? I get not doing them on a patient that isn't actively crashing.

Paracentesis? What? This is bread and butter EM. I can't even count the number I did during residency and do at least once per 1-2 months working part time. This is super low risk in the age of ultrasound and a can't miss diagnosis. Like other procedures, I don't call specialists for routine things that are expected of EM. Unless your IR folks are so bored they can do this in <2 hours, I don't get how this helps move a department.

 

[AlmostAnMD]

Thoras? I get not doing those. If they need it drained, they need a chest tube.

Pericardiocentesis? I get not doing them on a patient that isn't actively crashing.

Paracentesis? What? This is bread and butter EM. I can't even count the number I did during residency and do at least once per 1-2 months working part time. This is super low risk in the age of ultrasound and a can't miss diagnosis. Like other procedures, I don't call specialists for routine things that are expected of EM. Unless your IR folks are so bored they can do this in <2 hours, I don't get how this helps move a department.

That's fine, but if you ever cause even a single infection doing an invasive procedure you leave yourself wide open.

In addition the LP lawsuit I mentioned I can also mention:

A settled case involving a physician I know who intubated a patient for "agitation." He suffered complications on the floor from the vent and sued the ED doc who couldn't adequately explain why he intubated the guy.

A settled case in our area where someone felt the need to put a crash line in in someone for fluids who already had decent peripherals but hit an artery

You guys are trigger happy to do procedures, and that's great. I hope you do them for many years. But one day your daily paracentesis (WTF?) is going to introduce SBP or at least you'll get the blame for it even if it's not your fault. Guess who gets the blame????

As I mentioned, I do procedures when I NEED to do them. I'm not, as someone mentioned, afraid to do them. I've seen too many lawsuits about people doing unnecessary procedures to ever convince me to do them unless absolutely indicated.

 

[AlmostAnMD]

I was going to make a post about what I would do in a world without lawyers but concluded I wouldn't do more procedures, I'd just make more people DNR

 

[calvnandhobbs68]

The guy that did the LP and got sued for meningitis knew where his needle was. Remember that thread?

Every time you put a needle in a very protected space and it's not 100% life or death necessary to do so, don't do it.

This is the difference between docs that take risk management and docs that don't.

You can do 50 invasive procedures and they all go great. #51 gets an infection? Guess who just lost that lawsuit?

First, it was an epidural injection, not a diagnostic LP. Highly doubt they would have even settled if it was a diagnostic LP evaluating for meningitis..and I definitely wouldn't use that as a reason to avoid doing LPs. Plus it was a BS case anyway...sometimes BS cases end up getting settled cause it's cheaper than dealing with it. Oh well. That's why malpractice insurance attorneys exist. Anyone can sue you for anything in the great US of A.

 

[namethatsmell]

The guy that did the LP and got sued for meningitis knew where his needle was. Remember that thread?

Every time you put a needle in a very protected space and it's not 100% life or death necessary to do so, don't do it.

This is the difference between docs that take risk management and docs that don't.

You can do 50 invasive procedures and they all go great. #51 gets an infection? Guess who just lost that lawsuit?

I consider myself fairly risk averse, but this sounds a bit extreme. I agree that you don't want to be trigger happy, but the flip side of the coin carries risk as well and can be bad for patients. While you can be sued for anything you do, you can also be sued for things you elect not to do.

Misadventures happen in medicine and the system, as flawed as it is, generally doesn't expect you to be perfect (unless you're in Chicago et al). If you're doing an appropriate procedure, have informed/implied consent, and performed said procedure within the bounds of acceptable practice and an infection occurred (a known complication of every procedure that goes through skin)...then it's unlikely you have anything medicolegal to really worry about. Even if the patient tried to sue, it'd be unlikely to go anywhere.

To think of it another way: if surgeons were sued for every wound complication, infection, bleeding, damage to a surrounding structure, post-op pain etc from their procedures...would we still have surgeons?

 

[GeneralVeers]

Anyone frequently admitting patients with cirrhosis should be performing paras. AKI, altered mental status, fever, abdominal pain - all would necessitate a paracentesis to inform management. A thoracentesis, on the other hand...

As far as the pericardiocentesis - I have done one in a traumatic arrest scenario in the field. I don't think having done this procedure multiple times should be included in anyone's metrics for a "solid program".

Sure in the ivory tower. In the community it's antibiotics and let IR sort it out in thr morning.

 

[SpacemanSpifff]

Traumatic arrest = open chest.

Yeah... not in the back of an ambulance as an R2. Two finger thoracostomies, some blood, and a needle in the pericardium is as good as you're going to get in the US.

Sure in the ivory tower. In the community it's antibiotics and let IR sort it out in thr morning.

As others have stated, it's a simple, quick procedure that can change management. I do it at the community ED's I work at. To each their own.

 

[WilcoWorld]

If I'm honest with myself I'd say that 80-90% of the time I do a therapeutic thoracentesis in the ED is to get the resident a procedure, only about 10-20% I've done in the ED were because the patient couldn't wait.

 

[Birdstrike]

I do procedures when I need to do them.

I haven't been sued.

Beyond that, do a pericardiocentesis every shift the rest of your life, regardless of indication. It's your career, not mine.

99% of physicians in high risk specialties get sued.
75% of physicians in low risk specialties get sued. -NEJM

While that's awesome that you avoid procedures you consider "high risk," that's not the number one cause of lawsuits. The number one cause of lawsuits, is failure/delay in diagnosis. -Medscape.

Hopefully, you'll get lucky and never be sued. But it doesn't take much for a lawyer to take a bad/sad outcome, sprinkle in some false or hyperbolic accusations and use a frivolous claim to shake a settlement out of your malpractice carrier.

 

[Dr Mantis Toboggan]

my favorite para story is during residency there was a medicine team at our local VA. they got a therapeutic para started and left the intern to finish while the team got lunch. 10 min later the intern rejoins the team (it was an expected large volume tap).

senior asks “what happened? why are you done so soon?”

intern replies “oh it’s not done, I just showed the patient how to change out the bottles himself.”

senior runs back up there, finds the vet calmly doing just that, no problems whatsoever...


least favorite thora story. when I was in academics someone tapped a lung, didn’t know they were anticoagulated, they bled out and died

 

[Groove]

Man, I haven't done a thoracentesis since residency. It takes a lot to make me glove up for a paracentesis. The pt better be borderline respiratory distress from the ascites. They are just so damn time consuming. I flat out refuse if there are no vacuum bottles. The hand pump thing is outrageous and I get sweaty and cramped up. The reality is that if they are so full that they need a therapeutic tap, then it's incredibly easy to just admit them and put in a consult for IR or GI which is usually what I end up doing. Occasionally, I will tap and d/c myself in the ED. If I just need a diagnostic tap, I just use an 18g needle and take out as much as I need for the sample. Let's be honest though, most of these pt's can totally wait for the tap. Rarely does it need to happen right there in the ED. It's not a difficult procedure but these things are like complex lacs...they just grind you to a halt and greatly impair flow.

As for pericardiocentesis. I've done two since residency. Both were while waiting for CT surgery. One was assisting a colleague who asked me if we should tap the effusion on a pt that was coding. I would say those opportunities are pretty rare. The effusion has to be pretty damn big for me to feel that it's emergent. That or impending arrest, etc..

 

[turkeyjerky]

Sure in the ivory tower. In the community it's antibiotics and let IR sort it out in thr morning.

Definitely not the case at the 10 community hospitals I've worked at.

Let's be honest though, most of these pt's can totally wait for the tap. Rarely does it need to happen right there in the ED. It's not a difficult procedure but these things are like complex lacs...they just grind you to a halt and greatly impair flow.

That's not really supported by the evidence. See Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis - PubMed (plenty of other published data). I guess if you're planning on admitting them anyway and covering empirically they can wait for the inpatient team to do it. But it seems kinda lazy to me, and some of these patients can be discharged after a negative tap. (totally agree w/ you on TP though)

I just don't really get this attitude of actively trying to avoid procedures. Isn't that why we went into this field? I sure as hell didn't go into EM in order to be a CMG consult monkey and liability sponge.

As for pericardiocentesis. I've done two since residency. Both were while waiting for CT surgery. One was assisting a colleague who asked me if we should tap the effusion on a pt that was coding. I would say those opportunities are pretty rare. The effusion has to be pretty damn big for me to feel that it's emergent. That or impending arrest, etc..

WTF? How much deader can you make them?

 

[Groove]

Definitely not the case at the 10 community hospitals I've worked at.


That's not really supported by the evidence. See Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis - PubMed (plenty of other published data). I guess if you're planning on admitting them anyway and covering empirically they can wait for the inpatient team to do it. But it seems kinda lazy to me, and some of these patients can be discharged after a negative tap. (totally agree w/ you on TP though)

I just don't really get this attitude of actively trying to avoid procedures. Isn't that why we went into this field? I sure as hell didn't go into EM in order to be a CMG consult monkey and liability sponge.


WTF? How much deader can you make them?

I'm talking about therapeutic taps, not diagnostic taps for SBP. It's just not an emergent procedure most of the time, no matter how you spin it. Most of these pts needed to schedule an appt with their GI doc for an elective tap in the clinic. All you do by tapping them in the ED is reinforce chronic abuse of the system and irresponsible utilization of ED resources in an era where we have none to spare.

 

[turkeyjerky]

I'm talking about therapeutic taps, not diagnostic taps for SBP. It's just not an emergent procedure most of the time, no matter how you spin it. Most of these pts needed to schedule an appt with their GI doc for an elective tap in the clinic. All you do by tapping them in the ED is reinforce chronic abuse of the system and irresponsible utilization of ED resources in an era where we have none to spare.

Totally, 100% agree with you then. Even more reason I like to do diagnostic taps--patients get to suffer through the pain of the procedure, without any relief

 

[southerndoc]

99% of physicians in high risk specialties get sued.
75% of physicians in low risk specialties get sued. -NEJM

While that's awesome that you avoid procedures you consider "high risk," that's not the number one cause of lawsuits. The number one cause of lawsuits, is failure/delay in diagnosis. -Medscape.

Hopefully, you'll get lucky and never be sued. But it doesn't take much for a lawyer to take a bad/sad outcome, sprinkle in some false or hyperbolic accusations and use a frivolous claim to shake a settlement out of your malpractice carrier.

I've been sued three times. One for a missed diagnosis in a patient I inherited (wasn't even formally signed out to me), one for a guy's bill (he was told by hospital $1000 would satisfy his bill but they told him it would reduce it by 50%), and one that is ongoing that is really frivolous and hopefully I will get dropped from. The first one I was dropped immediately after deposition (I actually figured out what was going on). The second was a small claims suit, and the judge ordered him to pay the physician bill in full in cash and gave him a stern talking to for naming me in the suit. The third is an unbelievable reason for being sued. I will post about it when it's closed because it truly is something that will change practice.

I don't feel like I'm a bad doc. In my 12 years of practice, I have never had an inappropriate case reviewed by MCE (our quality committee).

 

[GeneralVeers]

I'm talking about therapeutic taps, not diagnostic taps for SBP. It's just not an emergent procedure most of the time, no matter how you spin it. Most of these pts needed to schedule an appt with their GI doc for an elective tap in the clinic. All you do by tapping them in the ED is reinforce chronic abuse of the system and irresponsible utilization of ED resources in an era where we have none to spare.

Correct. For many of them, if it's after 3PM and they don't need it urgently, I'll get labs then have them come back the next morning to get it done during business hours. This really pisses them off, but it's better than using a bed overnight to babysit them.

 

[Birdstrike]

I've been sued three times. One for a missed diagnosis in a patient I inherited (wasn't even formally signed out to me), one for a guy's bill (he was told by hospital $1000 would satisfy his bill but they told him it would reduce it by 50%), and one that is ongoing that is really frivolous and hopefully I will get dropped from. The first one I was dropped immediately after deposition (I actually figured out what was going on). The second was a small claims suit, and the judge ordered him to pay the physician bill in full in cash and gave him a stern talking to for naming me in the suit. The third is an unbelievable reason for being sued. I will post about it when it's closed because it truly is something that will change practice.

I don't feel like I'm a bad doc. In my 12 years of practice, I have never had an inappropriate case reviewed by MCE (our quality committee).

Twice, here. I met the standard of care in both. Nevertheless, being dragged through the process taught me a lot. I was trained well, by very lawsuit-avoidant attendings who were worried about "getting sued" all the time. For years, I spent a lot of nervous energy focusing on lawsuit avoidance. Then, getting hit with two suits that were so ridiculous, where I clearly met (perhaps exceeded) the standard of care, taught how pointless all that worry was.

Now I just do what I think is right, treat patients with respect, and pay someone else to do the worrying for me.

 

[Birdstrike]

I've been sued three times. One for a missed diagnosis in a patient I inherited (wasn't even formally signed out to me), one for a guy's bill (he was told by hospital $1000 would satisfy his bill but they told him it would reduce it by 50%), and one that is ongoing that is really frivolous and hopefully I will get dropped from. The first one I was dropped immediately after deposition (I actually figured out what was going on). The second was a small claims suit, and the judge ordered him to pay the physician bill in full in cash and gave him a stern talking to for naming me in the suit. The third is an unbelievable reason for being sued. I will post about it when it's closed because it truly is something that will change practice.

I don't feel like I'm a bad doc. In my 12 years of practice, I have never had an inappropriate case reviewed by MCE (our quality committee).

P.S. On the subject of procedure-avoidance as protecting from lawsuits, brought up by @AlmostAnMD

Decade in EM: 2 frivolous lawsuits, that had nothing to do with procedures.
Decade post-EM, putting needles millimeters from people's cervical spinal cords, 100% of which are elective: No lawsuits (knock on wood).

 

[AlmostAnMD]

It's about mitigation. I doubt I'm missing a diagnosis by admitting these patients.

However, good things can happen when you put things in cavities. So can bad things. If they don't need to be done in the ED, I won't do it. You're technically a specialist. If something happens when you're putting needles in a protected space, people will think at least I didn't do it.

 

[Birdstrike]

It's about mitigation. I doubt I'm missing a diagnosis by admitting these patients.

However, good things can happen when you put things in cavities. So can bad things. If they don't need to be done in the ED, I won't do it. You're technically a specialist. If something happens when you're putting needles in a protected space, people will think at least I didn't do it.

I'm not saying you're wrong. In fact, I agree with your idea of not doing procedures in the ED, that can be avoided. I did that constantly in the ED, mainly to save time.

 

[The Knife & Gun Club]

Doesn’t law suit avoidance kind of become unnecessary at some point?

I believe WCI did a segment on this where he looked at the risk of an above policy limits judgement and it was virtually nil? Like 1:10,000 lawsuits or something.

now obviously if you’re outside your scope or negligent that’s different, but for run of the mill procedures it seems kind of silly

 

[namethatsmell]

I've been sued three times. One for a missed diagnosis in a patient I inherited (wasn't even formally signed out to me), one for a guy's bill (he was told by hospital $1000 would satisfy his bill but they told him it would reduce it by 50%), and one that is ongoing that is really frivolous and hopefully I will get dropped from. The first one I was dropped immediately after deposition (I actually figured out what was going on). The second was a small claims suit, and the judge ordered him to pay the physician bill in full in cash and gave him a stern talking to for naming me in the suit. The third is an unbelievable reason for being sued. I will post about it when it's closed because it truly is something that will change practice.

I don't feel like I'm a bad doc. In my 12 years of practice, I have never had an inappropriate case reviewed by MCE (our quality committee).

Ugh that's lame. Sorry you're going through this. It'll likely get tossed.

Twice, here. I met the standard of care in both. Nevertheless, being dragged through the process taught me a lot. I was trained well, by very lawsuit-avoidant attendings who were worried about "getting sued" all the time. For years, I spent a lot of nervous energy focusing on lawsuit avoidance. Then, getting hit with two suits that were so ridiculous, where I clearly met (perhaps exceeded) the standard of care, taught how pointless all that worry was.

Now I just do what I think is right, treat patients with respect, and pay someone else to do the worrying for me.

Agree. Remember that big study showing that the only strong predictor of a doc being sued was how long they practiced for (not the state they practiced in, their years of experience, etc)?

Provider and Practice Factors Associated with Emergency Physicians Being Named in a Malpractice Claim

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency ...

www.ncbi.nlm.nih.gov

The attempts to try to capture the factors that predict lawsuit likelihood/trends is really all over the place. And at some point we have to accept we can't catch the wind.

I do what's in the best interest of the patient, treat people with the golden rule, and then let the chips fall where they may.

I'll admit I still sometimes take some extra time to chart wisely if I have a high risk pt. It's anecdotal and without evidence, but it let's me sleep well at night.

 

[Birdstrike]

Ugh that's lame. Sorry you're going through this. It'll likely get tossed.



Agree. Remember that big study showing that the only strong predictor of a doc being sued was how long they practiced for (not the state they practiced in, their years of experience, etc)?

Provider and Practice Factors Associated with Emergency Physicians Being Named in a Malpractice Claim

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency ...

www.ncbi.nlm.nih.gov

The attempts to try to capture the factors that predict lawsuit likelihood/trends is really all over the place. And at some point we have to accept we can't catch the wind.

I do what's in the best interest of the patient, treat people with the golden rule, and then let the chips fall where they may.

I'll admit I still sometimes take some extra time to chart wisely if I have a high risk pt. It's anecdotal and without evidence, but it let's me sleep well at night.

Great attitude to have.

 

[deleted547339]

Traumatic arrest = dead.

After spending maybe 6 months in a trauma icu in fellowship I can tell you this is definitively not true.

 

[southerndoc]

After spending maybe 6 months in a trauma icu in fellowship I can tell you this is definitively not true.

So you've got a bunch of prehospital traumatic arrests that survived to hospital discharge with a CPC of 1 or 2?

 

[deleted547339]

So you've got a bunch of prehospital traumatic arrests that survived to hospital discharge with a CPC of 1 or 2?

Not prehospital. But I was surprised at the number of open chests who got discharged home.

 

[southerndoc]

Not prehospital. But I was surprised at the number of open chests who got discharged home.

Arrest in the ER, yes, possible to survive. Arrest in the field and arrives without ROSC, chances are zilch. This is why my paramedics do not initiate CPR on traumatic arrests except in rare circumstances. They are very good at cardiac arrests (we have a 13% survival-to-discharge with CPC 1/2), but we realize the futility in working prehospital traumatic arrests.

 

[deleted547339]

I think we’re in agreement. I was just surprised by the number of post Ed-thoracotomy patients who live if they can make it out of the ED in fellowship.

Arrest in the ER, yes, possible to survive. Arrest in the field and arrives without ROSC, chances are zilch. This is why my paramedics do not initiate CPR on traumatic arrests except in rare circumstances. They are very good at cardiac arrests (we have a 13% survival-to-discharge with CPC 1/2), but we realize the futility in working prehospital traumatic arrests.

 

[Franzd'Epinay]

I've been sued three times. One for a missed diagnosis in a patient I inherited (wasn't even formally signed out to me), one for a guy's bill (he was told by hospital $1000 would satisfy his bill but they told him it would reduce it by 50%), and one that is ongoing that is really frivolous and hopefully I will get dropped from. The first one I was dropped immediately after deposition (I actually figured out what was going on). The second was a small claims suit, and the judge ordered him to pay the physician bill in full in cash and gave him a stern talking to for naming me in the suit. The third is an unbelievable reason for being sued. I will post about it when it's closed because it truly is something that will change practice.

I don't feel like I'm a bad doc. In my 12 years of practice, I have never had an inappropriate case reviewed by MCE (our quality committee).

I know you can't divulge any significant details, but are you able to elaborate in general terms on how it is practice-changing even though it's also frivolous? Will you be changing how you communicate with others, how you work-up a diagnosis, how you chart, or something else?

 

[southerndoc]

I know you can't divulge any significant details, but are you able to elaborate in general terms on how it is practice-changing even though it's also frivolous? Will you be changing how you communicate with others, how you work-up a diagnosis, how you chart, or something else?

Stay tuned.

 

[MechEDoc]

Sure in the ivory tower. In the community it's antibiotics and let IR sort it out in thr morning.

What's IR? Oh yeah, you're in a bigger community site than I am. IR involves a transfer.

 

[GeneralVeers]

What's IR? Oh yeah, you're in a bigger community site than I am. IR involves a transfer.

That makes an easy dispo then...

 

[southerndoc]

That makes an easy dispo then...

Not really. I turn down transfers left and right lately due to lack of capacity to accept the patient. Maybe in a non-pandemic situation facilities have the capacity to accept transfers for IR, but lately hardly any facility has capacity.

 

[WilcoWorld]

Not really. I turn down transfers left and right lately due to lack of capacity to accept the patient. Maybe in a non-pandemic situation facilities have the capacity to accept transfers for IR, but lately hardly any facility has capacity.

A great point that also casts doubt on the argument I've seen on this forum that EP's don't need to do procedures like LP/thoracentesis/paracentesis "because you can just admit and let IR do it."

 

[Groove]

Not prehospital. But I was surprised at the number of open chests who got discharged home.

Interesting. None of ours survived in residency. I think the closest one got up the elevator to the OR and arrested about 5 or 10 mins into surgery. I've cracked a single chest in the community since graduation on a young KSW that arrested in front of me and he essentially exsanguinated while I stitched up his right ventricle but I can't say that I was too surprised as we weren't a trauma center and didn't have the kinds of resources to quickly respond to that sort of case. Everything I've always read has abysmal survival statistics from emergent open thoracotomies.

 

[doggydog]

Interesting. None of ours survived in residency. I think the closest one got up the elevator to the OR and arrested about 5 or 10 mins into surgery. I've cracked a single chest in the community since graduation on a young KSW that arrested in front of me and he essentially exsanguinated while I stitched up his right ventricle but I can't say that I was too surprised as we weren't a trauma center and didn't have the kinds of resources to quickly respond to that sort of case. Everything I've always read has abysmal survival statistics from emergent open thoracotomies.

Are you telling me that anecdotal evidence might not tell the true story when it comes to patient outcomes?

 

[Groove]

Are you telling me that anecdotal evidence might not tell the true story when it comes to patient outcomes?

The most promising data is from 2000 and is ripe for debate. It's about 8% for penetrating trauma and less than 2% for blunt trauma. I've always been incredulous about the 8%. That's at a trauma center where you've got an entire trauma team prepped and ready to go. What do you think the statistics are for most "non trauma centers" such as a community ED where the surgeon might be driving in from home or stuck in a case in the OR and on his way down to the ED? The nurses meanwhile are trying to clear the cobwebs and scrape any memory or experience with mass transfusion protocols that may or may not be clearly defined or in place at your hospital. The rates are abysmal. Those environments reflect where most of us work, so if you're unlucky enough to be involved in one of these throughout any stretch of your career at a community ED, your anecdotal experience will reflect my own I would wager. The CT surgeon who was screaming at me on his cell phone NOT to crack the chest knew all this but I was young, fresh and newly graduated following everything by the book and lacked some of the wisdom that I possess today.

 

[GassYous]

Interesting. None of ours survived in residency. I think the closest one got up the elevator to the OR and arrested about 5 or 10 mins into surgery. I've cracked a single chest in the community since graduation on a young KSW that arrested in front of me and he essentially exsanguinated while I stitched up his right ventricle but I can't say that I was too surprised as we weren't a trauma center and didn't have the kinds of resources to quickly respond to that sort of case. Everything I've always read has abysmal survival statistics from emergent open thoracotomies.

Had a patient that was stabbed in the chest. They opened him up in the ED and the trauma team found a hole in the rv and stapled it before bringing him up to the OR. Apparently he walked out of the hospital.

 

[southerndoc]

Had a patient that was stabbed in the chest. They opened him up in the ED and the trauma team found a hole in the rv and stapled it before bringing him up to the OR. Apparently he walked out of the hospital.

Great story. Of course for every one of those we all have >100 of those that didn't make it.

I personally know of two surgeons who have gotten cut doing a thoracotomy. One with a scalpel and another on a broken rib.

 

[The Knife & Gun Club]

I still think it makes sense to try though even if you know it’s got a low chance for survival. Traumatic arrest in the ED with a potentially repairable source of bleeding is salvageable. The amount of low/no perfusion time for the brain could potentially be just a few minutes depending on that you find inside.

Now I’m not talking about clamshelling people with blunt trauma OHCA. We all know those survival rates are virtually 0. But there’s a subset of patients that could be helped, even if it’s 1/20 that’s worth a shot, not like they’re getting any deader.

It seems silly to me to throw up your hands and not try just because the chances of mobilizing the surgeon and having your nurses actually figure out how to use the level1 infuser is low.

 

[alpinism]

London HEMS has a published 20% survival for prehospital thoracotomies performed for stab wounds.

If they can save 1 of 5 patients in the ambulance there's no excuse for not trying in the emergency department.

 

[southerndoc]

London HEMS has a published 20% survival for prehospital thoracotomies performed for stab wounds.

If they can save 1 of 5 patients in the ambulance there's no excuse for not trying in the emergency department.

No, these are two different populations. Their survival rate is based on prehospital arrests where the physician is at the scene (London HEMS is staffed by a physician/paramedic combo).

To say that someone in the field can survive with CPR enroute and then get an ED thoracotomy can survive is misapplying the research for prehospital thoracotomies. We must stick with the research that ED thoracotomies done on OHCA have abysmal survival rates as that is the way the US practices. If we move to a model where EMS physicians are responding to scenes and doing thoracotomies, then we can look at that population's research. If London HEMS waited until the patient was transported to the ER, then their ED thoracotomies would have the same survival rate as our ED thoracotomies.

 

[namethatsmell]

No, these are two different populations. Their survival rate is based on prehospital arrests where the physician is at the scene (London HEMS is staffed by a physician/paramedic combo).

To say that someone in the field can survive with CPR enroute and then get an ED thoracotomy can survive is misapplying the research for prehospital thoracotomies. We must stick with the research that ED thoracotomies done on OHCA have abysmal survival rates as that is the way the US practices. If we move to a model where EMS physicians are responding to scenes and doing thoracotomies, then we can look at that population's research. If London HEMS waited until the patient was transported to the ER, then their ED thoracotomies would have the same survival rate as our ED thoracotomies.

I was just about to say the same thing re: two different patient population. Although my rationale was different.

We Americans would probably be harder to kill if we had to suffer through a childhood filled with Marmite like the Brits.

 

[GeneralVeers]

London HEMS has a published 20% survival for prehospital thoracotomies performed for stab wounds.

If they can save 1 of 5 patients in the ambulance there's no excuse for not trying in the emergency department.

There is no point unless you are in a trauma center. In the community surgeons would. Never come in for this. Thoracotomy is futile unless the patient can be transferred to the OR ina timely manner.