KBW’s Guide to an emergency thoracotomy

Every now and again something happens at work that is just so unbelievably exciting that you can’t quite believe your luck, one of the most exciting things for me is penetrating chest trauma requiring an emergency thoracotomy, also know as “cracking the chest”. If I was a boy I think it would give me an erection. As you may know from watching ER, Holby, Casualty etc this procedure can sometimes take place in the A&E department when it is known as an Emergency Department Thoracotomy (EDT) as opposed to an in theatre Emergency Thoracotomy(ET). EDT’s are performed usually by A&E doctors on the already dead or practically dead and have a correspondingly grim outcome. Not so the ET, this is handed over to the surgeons to be done in theatre, pretty quickly with no time wasting but you have sufficient time to get them asleep and on the table and to wash your hands.

And so, in the Big Hospital fairly recently I was lucky enough to get the call from one of my colleagues (I use the term loosely) in A&E that he had a young male who needed an ET. This particular way of referring a patient to us can irritate some of my colleagues and leads to time wasted arguing that “I’m the fucking surgeon, I’ll decide who needs an operation”. I am less easily annoyed than the boys and don’t mind that people point out the obvious from time to time. I especially don’t mind when they are sending me something so fun as cracking a chest.

En route to the patient you need to organise theatre and let the anaesthetist know you may have an emergency case, you also need to remain calm, chances are it is all going a bit crazy down in the emergency department. The basic information you need is according to ATLS principles, get an AMPLE history (allergies, meds, past medical history, last ate, events) and find out from A and E what they have organised already. In a perfect hospital, which Big Hospital is not, you should have been called to A&E whilst this person was en route and be waiting in the “resus room” wearing your apron and gloves and ready to work as one little cog in a super slick team. The reality is that the patient has usually been in the hospital for an hour whilst the first aid doctors put in some lines and order some blood before deciding that actually, they need a surgeon after all.

All surgeons should know that the indications for an ET are;
Haemothorax on CXR with >1500ml blood on insertion of chest drain or >200ml/hour output 2 hours after inserting drain.
Haemothorax on CXR with <1500ml blood on insertion of chest drain but CT evidence requiring surgical intervention (gross contrast extravasation, air leakage)
Pericardial tamponade
Massive air embolism
Ongoing blood transfusion requirements
Physiological indications (patient is compromised despite less than 1500ml lost)

Having decided what you need to do and why you are doing it you need to get on with things. In Big Hospital we are very CT dependant and most people would go through the CT scanner if they were stable enough. The diagnosis is usually pretty obvious as you can see from the picture below and clinical judgement should be used; either approach is justifiable in certain circumstances. Some surgeons are old school and would always go to theatre without a CT and sometimes you can’t wait that long to do the scan (see Radiology Rant).

How to open the chest? You should know how to do a so called clam shell thoracotomy, it's a bit like popping the bonnet and gives access to everything using a knife and some heavy scissors. I recommend this article by Wise et al which is a beautiful guide on how to do this procedure. This is more of an EDT style thoracotomy and usually if a surgeon is doing it in the UK it will be via an anterolateral thoracotomy.

Patient needs to be supine and airway protected with an ET tube and an anaesthetist and it goes without saying that theatre is prepped appropriately and that you have the right kit (rib spreaders, periosteal elevators and bone cutters (if you need to take out some rib bits) gigli saw, heavy scissors, blade, chest drains etc) Good lighting, 2 suctions, decent assistance.

5th intercostal space, cut from the sternum to the mid axillary line, push the breast up and out of the way, cut down swiftly through skin and fat (there isn’t much fat in these people-stab chests are usually young males) and you’ll see intercostal muscles covered in a fine fascia, like in a chest drain get a hole made in this fascia with a knife and the scissors and poke your finger in and push lung down. Without cutting lung, open up the muscles, stay on the underside of a rib, this is tough and requires a lot of force to do this, the ribs don’t want to open up. Rib spreaders in and open the chest up. Unless you are a cardiac surgeon or an oesophageal surgeon you are now in unfamiliar territory but the diagnosis is usually obvious and you can sew up holes or staple off lobes if required. Foley catheters can be used to plug holes and arrange transfer to a cardio thoracic unit. This is not the time to save your hospital money and expensive staplers are the answer to lung resections for non specialists.

Fix the problem and pack them off to ICU for a brief period of physiological correction and be pleased that for once you have done something that instantly saved a life and made someone significantly better. Unfortunately there is always a catch, the police want a statement from you and then about 10 months down the line you will receive a court summons to attend the trial. This can be masterfully avoided by making the briefest and blandest of statements to the police that no lawyer would dispute and thus they have no need for you to attend court. I’m not a lawyer (obvs) but keep it short and sweet e.g “I was on duty as the surgeon on call and attended the patient Mr Six Girlfriends in the emergency department where he had 3 stab wounds over his left nipple which were made with a sharp instrument. I took him to theatre for an emergency operation and sutured a 1 cm hole in his atrium. He was unwell. He nearly died. He was in hospital 7 days. He has a big scar.”

It doesn’t happen very often to most surgeons in the UK so when it does, get it right and enjoy feeling like you are in ER for the day. Blood splatters on your face are optional.

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Make your night shift less shite shift

Here are my rules for surviving and indeed enjoying nightshift:

1. Do not forget to bring the following: a toothbrush, a book or a magazine, fruit, red bull or other caffeinated beverage to be chugged down pre theatre at 4am and some money.

2. Do not eat all the crap that the nurses have brought in (usually crisps and huge bags of Haribos) it will make you feel shit.

3. Eat well, drink plenty. If you sleep all day and are working at night it’s easy to forget to drink as there are no natural breaks like lunch time during a night shift.

4. See daylight at some point each day and spend a small amount of time outdoors.

5. Bring something warm to wear at night, even in summer. Being tired and cold is miserable.

6. Night shift time moves at a different pace to day time. When something goes appallingly wrong it seems to move fast and what feels like  ten minutes of action actually takes place over an hour, it’s a strange phenomenon that you are made aware of in the mortality and morbidity meeting when someone asks you, “why did it take you two hours to get the patient to the CT scanner?”.  The opposite is true of quiet nights, when time stands completely still.

7. You will not do that paper that you need to write whilst on night shift, so don’t kid yourself that you might.

8. Sleep when you can, if it’s quiet at 10pm get to bed, you never know when it will all go wrong. Sleeping from 10pm to 2am is better than messing about until 2am and then not getting to bed at all.

9. Remember that every night shift holds the possibility of it being that magical night that comes along once a year when you sleep all night, undisturbed by anyone.

not tonight

And don’t start something you won’t be able to finish.