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Heroic Measures

ED thoracotomy is as far as we ever go to save a life. In fact, it is sometimes so far away that we now have rules to to prevent us from getting lost while performing this procedure. By that I mean, we do not do it unless there is at least a remote chance of saving a life so that we do not waste hospital resources and time when there is not even that distant chance of life.

In essence, the emergency thoracotomy is our most hands on procedure for resuscitating a pulseless patient. There are cardiac arrests, infarctions, strokes, broken bones, allergic reactions, but none of them require as must hands on manipulation and active treatment.

Though Stanford receives far more trauma than people assume, it is fair to say that the gunfire of the crack era has been displaced by motor vehicles. There is unfortunately enough violence to become all to proficient in treating penetrating trauma. Yesterday, a young man was shot in his stomach on a saturday night in Silicon Valley. The initial report suggested that he did not have any pulses and that the paramedics were performing CPR. Our night staff is very composed and began preparations for his arrival in 5 minutes. Xray plate to the bedside, call respiratory therapy to assist with ventilation, bring blood from the blood bank, call the trauma team, bring in the ultrasound, glove hands and put on masks, and assign roles to each individual in the room.

Often these traumas turn into an unfocused cacaphony of voices and commands much to the detriment of the patient and those trying to help. When a child is involved it is almost impossible to prevent. This time everyone found a place in the room and waited. It was our day to run and I made sure everyone was on the same page, had a role, and had their equipment ready.

From what I hear, thoracotomies used to be more prevalent, usually performed during these pulseless traumas, often with little chance of success. Now, with improved evidence based research and better databases it is more clear when they are beneficial. A penetrating trauma patient without pulses but with observed signs of life stands a 5% chance of survival to admission by means of emergency thoracotomy. Now that's a loaded sentence. Most importantly it means that it is only useful in the specific circumstance when someone is shot (or stabbed, or something similar) and their heart can no longer pump blood, but they are still sort of alive. This excludes most car accidents and people who are just dead which is a large proportion of serious traumas.

Without the trauma team there I began to thing that it would be my first chance to perform a thoracotomy because the initial description sounded like an indication for thoracotomy. As I reviewed the procedure in my head we heard that the ambulance parked in the back. At the moment it rolled in and so too did the trauma team. Surpringly, the room stayed quite as we learned about the man's 2 shots to his stomach, the attempted resuscitation, and intubation in the street. I then asked another ED resident to confirm the placement of the breathing tube while I listened for breath sounds and checked for pulses.

Breath sounds, but no pulses. The head of trauma at Stanford often tells us that the first thing we should do at a trauma is to check our own pulses. Mine was moving a little fast, but I continued with as much composure as possible. A nurse began CPR as I placed two small holes into each chest cavity and then opened up the thoracotomy tray.

Sure, I did it on cadavers, but it surprised me to cut through the chest with more emphasis on speed, and less concern for precision. It was even more surreal to break open the ribs and see the lungs filling and deflating like a machine. Beneath the lungs the man's heart quivered. Ventricular fibrillation is what it looked like; a state where the heart does not adequately pump blood. I held his heart in my hand and assisted it in the pumping process to get the blood to his brain while the trauma senior brought the electrodes to restart his heart. After one shock directly to his heart it pumped normally and we could suddenly feel pulses.

To everyone's surprise I had reached into his chest and restarted his heart. For a moment I wasn't sure what to do. More chest tubes? A foley? Another IV line? It was clear that whatever we did didn't leave him much time so the head of trauma shouted for us to get him ready for the operating room in 10 seconds, and we did.

That was my last interaction with him. He did survive for another 5 hours but ultimately lost too much blood and had too much internal damage to save. Last night I returned home with haunting images of his lungs pumping near my hands and his wasted life. Oddly, I watched the movie Why We Fight and felt even more sad for our actions. I couldn't help but feel the rope slip from my hands.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.