Thursday, December 4, 2008

ED Thoracotomy

I had to open up a patient's chest in the ED the other day. The outcome was predictable. The patient had been shot in the chest and arrived without vitals. Protocol mandates that you slice open the left thoracic cavity right there in the ER, right in front of everyone, the bright lights, the chaos and noise of the trauma bay, cops and nurses and orderlies standing around, mouths agape. You do it right there in front of everyone.

When I was a surgical intern, it was considered a huge coup to get a ED thoracotomy. We all yearned to get one. The excitement! Such a cool procedure! God I hope someone rolls in on the verge of death! The glory! I would get pissed off if one of the other interns got to do one.

But there's nothing glorious about an ED thoracotomy. It's brutal and raw and completely dehumanizing. Here's what happens. Patient arrives in obvious extremis. Airway is established. Gunshot wound to the chest. You splatter betadine haphazardly all over the left ribcage. Someone hands you a #10 blade. Everyone is shouting and racing around and someone is putting in a femoral line and there's someone at the head of the bed bagging the patient. You notice that there's nothing on the monitor. No blood pressure. No tracing on the EKG strip. You push the cold black steel into the patient's flesh. And not like in the OR for an elective case, where you gently glide the knife along the skin surface. You press that sharp blade as deep as you can, firmly, with vehemence. Usually it's a young man, the anatomy clear and distinct. The intercostal muscles are then either cut with the knife or Mayo scissors. You're in the chest cavity seconds after the scalpel hits your hand. This releases a volcanic eruption of old and fresh blood. Someone hands you the rib retractor. It looks like a goddam bear trap. The prongs are wedged between the ribs and you crank open the chest with all your might. You can hear the cartilage and the bone snapping. It's awful. It's necessary. One in a hundred times. Just maybe you save someone. That one person out of a hundred. You clamp the aorta. You open the pericardium. You search for injuries. Counter-intuitively, isolated injuries to the heart are associated with better outcomes. Whipstitch it closed. Stick a finger in the leaking ventricle. But injuries to the pulmonary hila and aortic arch are less forgiving. You know this. You liberate 5 liters of blood from the chest. The aorta is flaccid. The heart is an empty, quivering, non-functional lost cause. It's already starting to turn blue. The patient is blue, blue lips and blue finger tips. Ten minutes have gone by. There's no pulse. There's nothing. Just a large gaping wound in a young man with his heart and his lung hanging out and his wasted blood all over your shoes and pants. He's cold and lifeless, right there in front of everyone, the cops and orderlies and the people passing by. You sign the papers and look for some family but there's no one there, so you just rip off your bloodied, ruined clothes and throw everything in the trash and put on scrubs and go home to your wife....

16 comments:

Bongi said...

not fun. the adrenals take a bit of time to recover.

rlbates said...

Not fun, but I can still recall the first and only one I was part of as a senior student rotating at Parkland ER (Dallas, TX). We didn't even take the time to put on gloves. This was pre HIV knowledge days.

Anonymous said...

yikes, dramatic post. I always assumed they split the sternum, like during elective heart procedures. Consider myself informed.

Frank Drackman said...

C'mon its gotta give you a Rush every time you yell "Rib Spreaders!!!" I mourn the day it was removed from the ACLS algorhythms....

Kellie said...

Surgery residency is weird. One is always hoping for bad things to patients. We always wanted the "big cases" which usually meant Bad diagnosis (pancreatic cancer = Whipple; cancer of the esophagus = esophagectomy; big trauma can = ED Thoracotomy)

ErDocNLA said...

You do mean "left chest", right? In you post you mentioned that you splashed betadine on the "right chest" which would be a strange place to start a thoracotomy (unless you're converting to a clamshell!)

The Happy Hospitalist said...

That was amazing.

Buckeye Surgeon said...

Eric-
You're right. That's what I get for trying to do three blogposts in one day. (In the first paragraph I did write "open the left thoracic cavity")

Dr. Val said...

Wow that was really well written. I felt as if I were there... so dramatic and so sad.

OHN said...

I am familiar with the area where you work and I would imagine that you get more than your share of young male shooting victims as patients. So sad.

Anonymous said...

Thank you.

Slammer04 said...

As a pre-med student, these blogs our about as close to the real thing as I can get, and as a reader of many med blogs, I must say, that was probably the most amazing post I have read. Awesome.

pinky said...

I remember coming across the remains of a man who had that done. I was shocked at how much blood was all over the place. And I thought the body kind of looked like a side of beef. This was 12 years ago. So maybe it is different now. But it was a sight you really don't forget easily.

red rabbit said...

Very sad. But very cool.

But very sad.

jlca said...

Very interesting but I would just leave everybody with a little fact. Thoractomy for massive blunt chest trauma is really a bad idea approaching 1 - 2%. On the other hand Thoracotomy for penetrating can be as high as 20%. Last night we opened a chest and fixed a hole in the left ventricle of a man that was stabbed. Great post.

Anonymous said...

lame