Messages from several Panolian Facebook friends: Do you really open people’s chest cavities in the ER?

Ah yes, the pinnacle of emergency medicine as well as emergency medicine TV dramas! While it is always better to be in the operating room under a controlled environment when having one’s chest cut open, there are some rare instances where it is necessary to cut open a patient’s chest in the ER.

This activity is usually why emergency medicine doctors go into emergency medicine; to “crack a chest open.” The medical term for opening the chest cavity is, thoracotomy. However, before we take this drastic action it is important to know when to do it as well as why to do it. Once the chest is open there is no turning back.

Keep in mind that deciding to open a person’s chest — and that’s the hardest part of this whole scenario, deciding — means that all other options have been completely exhausted. We are at the finish line. All medicines have been tried and failed. It’s either open the chest or stop living. As such this action has some specific criteria that are required before an ER thoracotomy is done. These criteria are set up so that we are truly offering the patient a chance at life and not just needlessly doing more harm than good.

First, the patient has to have suffered penetrating trauma. This means a gun shot wound (GSW) or stab wound. Car wrecks are usually out. That is typically considered blunt trauma.

Secondly, the patient has to have a pulse when they arrive at the ER and then lose their pulse in the ER while they are being worked on by the ER staff. This criteria is to make sure we really have a candidate who might benefit from opening their chest. If the patient doesn’t have a pulse when they come in the likelihood of bringing them back by opening their chest is close to zero.
Finally, the facility where all this is happening needs to have a surgeon and operating room that can immediately take them to surgery. In other words a full trauma team. Otherwise, this will all be for nothing, as it is a temporary life saving measure.

These patients can’t realistically be transferred to another hospital with their chest open.

Now that we know when to open a chest, what do we do when we get in there? There are three basic actions to take once in the chest. The first is what we so often see on TV, the open cardiac massage. This is where the doctor uses his hand to squeeze the heart to keep blood pumping around the body.

Secondly, we can clamp the aorta. This is the main vessel coming off the heart. If someone has massive bleeding this action can keep the blood from bleeding into the chest or abdomen and keep it circulating to the brain and more vital organs. This of course means no blood is going to the spinal cord which is why most patients that survive are paralyzed.

Finally a thoracotomy can be used to clap off parts of the lung that are undergoing massive bleeding.

As we can see, while a thoracotomy seems glamorous on TV it is only done as a last ditch, serious action that even if it saves the patient’s life, which is rare, may likely leave them with serious life-altering problems as a result.

Of course, it is very important to make this decision correctly and quickly. There was a doctor I knew in residency who, unfortunately, did not make the correct decision. This physician was working the trauma room when a GSW came in. As they were placing the patient on the bed the nurse called out that the patient had lost his pulse on the monitor.

Without hesitation or checking the patient for a pulse Dr. A called for a scalpel and began opening the chest. Just about the time he had exposed the heart this same nurse said,”Oh sorry he didn’t lose his pulse the monitor measuring his pulse has fallen on the floor.”

No matter how advanced our technology it’s always good to check the patient directly!
Ask Dr. Berry a question at dberrymd@hotmail.com.