Cut to the case!
Emergency doctors discuss cases and how to manage tricky situations in the Emergency Department.
Cut to the case!
thoracotomy
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Emergency Department Thoracotomy! Jonathan and Emma discuss indications, the "Seven Step" technique and an approach to training which can help to make this unfamiliar procedure familiar.
We've got pre-notification a 40-year-old male has been stabbed in the chest over the cardiac silhouette. Odds on, might have a tamponat. It's thoracotomy.
SPEAKER_01One of the best things for thoracotomy training is to really have this unfamiliar situation become familiar. So it's about really breaking it down into clear indication, but then really having a shared understanding of what the procedure involves.
SPEAKER_02Hi, it's Jonathan.
SPEAKER_01Hi, I'm Emma.
SPEAKER_02And this is Cut to the Case. And Emma, I've got a case. Okay, go ahead, Jonathan. I've got something that happened the other night, uh, and it's thoracotomy. So I thought we could talk about thoracotomy, but we could talk about um you know the teaching and how you get people on board with thoracotomy.
SPEAKER_01Well, tell me the case.
SPEAKER_02So so the case, so cut to the case is what you're saying. Yes. Um so we've got pre-notification a 40-year-old male has been stabbed in the chest, and we're hearing it's one single stab wound over the cardiac silhouette. Odds on might have a tamper. The story is heart rate of 130, um, and it's got an unrecordable blood pressure, but he's got signs of life, he's still talking to them, so he hasn't arrested.
SPEAKER_01Yeah.
SPEAKER_02And then not saying he's got a pneumothorax, they're just saying he's got a single stab to the chest and he's shocked. Okay. So we set up a team, yeah, and my role in the team is not to lead it, but to um to do procedures, and I'm asked to do procedures on the patient's right hand side. So I'm not on the normal thoracotomy side, and I'm scrubbed, ready to go. Um, and uh I'm gonna do vascular access and maybe decompressor test on that side.
SPEAKER_01Yeah.
SPEAKER_02And the patients about to come in, and we've done a team brief and we're talking about what to do, and then I I sort of looked across to the doctors who were gonna do the thoracotomy, and then it struck me I don't know them. Okay. And and I don't know how confident and capable they are to do the thoracotomy.
SPEAKER_01Okay, so you don't really have a shared understanding.
SPEAKER_02That's it. Okay. And I thought we could talk about what do you do in that situation.
SPEAKER_01Yeah, okay. Well, why don't we first talk about um pre-brief? So that uh sort of time before the patient arrives. Um how can you set that team up better so that you do know one who they are, uh their names, and their uh capability of being able to perform a thoroughcomy.
SPEAKER_02Well, we can do a one-time tea brief. We can do a one-teen brief. Obviously, ascertain, you know, get the names, introduce yourself, where are you from, what do you do, um, and uh then probably an outline of what we're expecting and a plan A and a plan B, and then usually I would ask them so when you're in this role, what will you do? Yeah, um, when the you know when the patient comes in. So and I'll get them to run through what they'll do. Yeah, and then we'll then hopefully we'll get a shared understanding and I'll get some gauge on how comfortable and capable they are.
SPEAKER_01Okay, that sounds great. That sounds like the beginning of that shared understanding. So should we digress for just a minute and really look at the indications for ED thericotomy? Do you want to quickly run through those, Jennifer?
SPEAKER_02So my understanding is your understanding. So my understanding. No, also so um, well, let's let's put it out there. There are a difference in survival rates quoted by different people in different countries. Um, but uh, and that that that that affects the indications. But our indications are so someone who's arrested uh uh within 10 minutes or arrested in front of you um and has a pericardial tamponart on ultrasound. So that's a good thing. That would be the main indication. Um and the second indication is someone who is profoundly shocked, yeah. So low blood pressure, so less than 70, but you've resuscitated them, so you've given them uh a MEP or you've given them a one-to-one transfusion and you've decompressed the chest, um, and they've got a tamponart. So in someone in that situation, that's an indication for a thoracotomy.
SPEAKER_01So what you've just done there is really outlined your understanding, and as I'm listening through your indications, I'm also ticking off, yep, that actually matches my understanding. Well, that's good. And that gives us the opportunity so that if my understanding is different to yours, we can correct it. So I guess that's the whole idea behind having a conversation around shared understanding. And so one of the best things for thorochotomy training is to really have this unfamiliar situation become familiar. So it's about investing in teams and training in teams and really breaking it down into clear indications as we just went through, but then really having a shared understanding of what the procedure involves. Um so we'll put up the uh seven-step procedure. The reason behind having this simple uh method is it allows you to do mental rehearsal. Jonathan, can I ask you, do you ever do mental rehearsal in the car on the way to work?
SPEAKER_02I uh well like I'm in the train these days, so um I tend to, it's free. Um no, I do, but like in this situation, in this case, I was actually doing the mental rehearsal. Okay. Because do you know why? I had nothing to do. So I'm you know, I'm sitting there scrubbed on the other side, thinking, okay, what am I gonna do when the patient comes in? What what would I actually do? And I find that's actually so powerful that sometimes I think I've actually done the procedure when I haven't actually done it because I've done the mental rehearsal. So I don't know whether you do that.
SPEAKER_01In the in the words of um uh one of my colleagues, never go where your mind hasn't already been. And so that's you know, that's one of the powers of mental rehearsal. And so when I'm thinking about uh the thorocotomy, I'm going through things like make the incision, and I need to know the location, and it's the same area that you're going in for your chest decompression, so the fifth intercostal space, and I'm just making that incision, then I'm spreading the ribs. Clearly, there's lots more layers in this, but these are the main steps that I'm going through. Spreading the ribs with your rib spreaders, uh, with the handle up and the axilla, packing away the lung, uh, opening the pericardium, delivering the heart, identifying control any injury, and then maintaining control until you can get to theatre with either a cardiothoracic surgeon or a trauma surgeon. So though they're the seven steps, but breaking them down into something that your mind can mentally rehearse means that my understanding can be shared with you, with the team leader, with the airway doctor, with the procedure nurse, and we've all got a shared understanding of what needs to happen in this highly critical procedure.
SPEAKER_02So so really what uh and I guess um we didn't run through the seven steps in this case. We didn't have to do it, right? We didn't run through it, but we did share the model about the indications and and you know why we would do it. But um uh that's a great sort of concept. So so I could have you know run across the other side and said, hey guys, um, you know, if we did do the thoracotomy, here are the steps that we'd go through. And maybe if when when you're actually doing it, uh just call them out, let me know so I know what you're up to.
SPEAKER_01I'm spreading the ribs.
SPEAKER_02Yeah, I'm spreading the ribs. I'm retracting the lungs. Yeah, and so it's I'm opening the pericardium. If something's not working or or it's not going the way we we expect, we can help each other. Yeah. And so we're on the same page.
SPEAKER_01Yeah.
SPEAKER_02Um so I love the seven steps.
SPEAKER_01Well, what we do in our training is we clearly go through some task work training. So we on a part task trainer, we're doing steps.
SPEAKER_02I don't have a shared, but we will show this model uh and look out, there's a video coming. We're gonna make the video uh of Emma doing the thorachotomy, so but with the seven steps.
SPEAKER_01But but essentially it's um there's the proceduralist, um, but there's also the assistant, there's also the scrub nurse, so they also need to have a shared mental model. But then there's other roles within the room. So there's the airway um doctor and nurse, and they need to have key steps identified in terms of when they've intubated the patient, ventilating the patient, they need to anticipate perhaps a return of blood pressure if indeed the tamponade is um reversed. But the team leader also has some steps, and so the way that we train our doctors is we rotate them through all of those roles, and that's really important for an ED team because as an ED doctor, you might be team leader, you might be airway doctor, you might be procedure assistant, you might be the proceduralist. But understanding all the key points of each role is really important, and it allows repetition because repetition really helps for these halo procedures.
SPEAKER_02And uh, as we've said, it's probably I mean, I don't know how many you've done, but it's something you don't do very often. So, but the mental rehearsal has kind of built it into your memory, so you think you've done it.
SPEAKER_00Yeah.
SPEAKER_02So and I think I've done the airway role and that, and I think I've done the helper role and that, and I think I've done the actual cutting role and that, and I've done the leadership role in that. So so I think I've sort of done it. So when it actually happens, I'm comfortable to do any of those roles. Yeah, good, yeah, yeah.
SPEAKER_01So I guess there's some key learning, and that key learning is really about trying to get some simplified ways of um teaching Halo procedures and combining your sort of teamwork communication with your task work. So back to your case, Jonathan. How did it go?
SPEAKER_02So well, what happened was we had the had the uh the briefing, as we said, the the patient came in. Blood pressure was not recordable initially, but when they came in, they'd already had two units of blood. He was actually talking to us, he looked really unwell. Yeah, um, blood pressure was 85, and there was nothing else to find. So he didn't have signs of a tension pneumothorax, it was right in the middle of the cardiac.
SPEAKER_01Did he have a tamponard?
SPEAKER_02Uh and he had a tamponard. Okay. So he had a tamponard with a blood pressure of 85. Yeah. And he was looking okay. So he was looking like he didn't need an ED thoracotomy. But I'll tell you what.
SPEAKER_01He didn't meet indications.
SPEAKER_02He didn't meet indications, but I tell you what, we were ready to go at any moment. So uh fortunately, we were able to do an OPSTA. Straight to theatre. Well, it wasn't straight to theatre, but it was pretty well straight to theatre. We're able to get him up to theatre where cardiah thoracics were able to do the thoracotomy. Um, and it it's a happy ending. Great. But for a while, uh as we were waiting, preparing, there was just that anxiety moment. Well, if the blood pressure is going to be 70 or sub-70 or a URS, what are we gonna do?
SPEAKER_01Yep, prepare for the worst, and that's your chance of making your outcomes as best as they can be. Yeah, so great.
SPEAKER_02So you had that clear moment of he doesn't meet our indications, which you'd shared, yeah, and he was able to go up to the and and it was all nicely shared, so so everyone was quite happy with the outcome on the way it worked, and I think it truly, if it was that he were to arrest in AD, we were ready to go. Yeah, yeah, we're gonna be fine. Stabbing the right ventricle, uh as as as the pathology usually is, and he's done fine.
SPEAKER_01Yeah, great, great. All right, shared knowledge and shared understanding.
SPEAKER_02Love it. I I love your catchphrases, Emma. So look, look out for the thoracotomy video, yeah, because that's coming. All right. See everyone. See everyone. Bye.
unknownTake a break.