CCT in Fly-cars

Surgeons are really expensive to train and the only times they're hanging around not doing anything is when they turn their phones off because a partner is covering. Other than that they're making money for themselves and the hospital. A widespread system of American surgeons dropping what they're doing to go to the scene of a trauma is the stuff of fantasy. And an ER doctor is not a surgeon.

An aortic cross clamp isn't the end of the intervention. It is only the beginning and it is only useful in very specific situations. Once applied, a very specific course of action needs to be planned and taken. And stupid quickly. Cross clamping without a plan and the ability to carry it out, is not undertaken often, if at all, at least by thoraco-vascular/CT surgeons. It surely shouldn't be by an ER doc.
 
I still like the idea of field REBOAs. Has a lot of the same practical and logistical limitations but is a much more obtainable goal than field thoracotomy.
 
Pond Life said:
Ive just completed an annual update with my service and we have been told that if a patient has blunt chest trauma cardiac arrest or peri-arrest that we are to notify HEMS immediately and if doctor on board they will come along and do a roadside clamshell thoracotomy with damage control surgery as required. Thing is it has to be in 10 minutes of the arrest or its a non starter.
The policy has been in place for 6 months now - haven't heard of any patients receiving this treatment as yet.
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That timeline is pretty much a non-starter period. Your arrival time post-arrest likely ate up the bulk of your "10 minutes of the arrest". Then you have to make the call, load staff and surgeon (who is not sitting in the lounge directly across from the helipad), then spin up, take off, land, etc. The response time window doesn't work.
 
E tank said:
Surgeons are really expensive to train and the only times they're hanging around not doing anything is when they turn their phones off because a partner is covering. Other than that they're making money for themselves and the hospital. A widespread system of American surgeons dropping what they're doing to go to the scene of a trauma is the stuff of fantasy. And an ER doctor is not a surgeon.

An aortic cross clamp isn't the end of the intervention. It is only the beginning and it is only useful in very specific situations. Once applied, a very specific course of action needs to be planned and taken. And stupid quickly. Cross clamping without a plan and the ability to carry it out, is not undertaken often, if at all, at least by thoraco-vascular/CT surgeons. It surely shouldn't be by an ER doc.
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Thoracotomy with cross clamping of the aorta is taught as part of an emergency medicine residency, and the emerg docs (not surgeons) do it prehospitally with London Air Ambulance and all the other sexy flight doc programs that people like to talk about.

You are correct though, that unless step 2 is "be at a trauma center with a surgeon very quickly" its a useless procedure. There is also some data that REBOA might be more effective/safer.
 
rescue1 said:
Thoracotomy with cross clamping of the aorta is taught as part of an emergency medicine residency, and the emerg docs (not surgeons) do it prehospitally with London Air Ambulance and all the other sexy flight doc programs that people like to talk about.

You are correct though, that unless step 2 is "be at a trauma center with a surgeon very quickly" its a useless procedure. There is also some data that REBOA might be more effective/safer.
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Right...anyone can be taught to throw an aortic cross clamp. That isn't the hard part. It's the guy that takes it off that needs to be around...

But I think there is a distinction between a huge-a** thoracotomy and possible X clamp and a REBOA, not the least of which is you can't cross clamp the aorta in zone 2 and 3 anywhere else than in an OR. An occluded aorta in zone 1 knocks out the mesenteric, spinal and renal arterial supply which can mean dead bowel and kidneys and possibly paraplegia in short order. Some might argue a dead person doesn't need kidneys so what does it matter, but the REBOA is a way better device in that the operator can decide and weigh the consequences of where he occludes the aorta.

A thoracotomy isn't of any use in an abdomino/pelvic injury, aortic occlusion in the chest for such an injury risks taking out bowel and kidney unnecessarily and a low (infra-renal) aortic X clamp outside the OR is not practical. So, yeah, REOBA.
 
Thoracotomy can be indicated in abdominal trauma, though it's not the best indication, purely for clamping the aorta in what would be REBOA zone 1 and knocking out all abdominal blood flow. You can't really control those bleeds with REBOA either because the celiac and SMA are superior to the renal arteries, and they're both in zone 2 anyway, which is (I don't know why) considered a no go zone for REBOA. REBOA you can clamp zone 1 or 3, and 3 maybe lets you control the IMA, but mostly the iliacs and below. A completely untested advantage is the ability to partially inflate the balloon and still try and allow some intestinal and renal blood flow, but I don't think anyone's actually studied how effective that could be.

Weirdly, one of the few "not recommended" indications for thoracotomy is blunt trauma with no signs of life, so I'm not sure why the above poster has that as an indication for HEMS, in addition to the fact that unless HEMS is on the initial dispatch it's probably too late anyway.
 
jwk said:
That timeline is pretty much a non-starter period. Your arrival time post-arrest likely ate up the bulk of your "10 minutes of the arrest". Then you have to make the call, load staff and surgeon (who is not sitting in the lounge directly across from the helipad), then spin up, take off, land, etc. The response time window doesn't work.
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Quite agree, I think its a daft idea and unachievable - the tutor couldn't grasp why we thought it wasn't going to work. May do in London where you have HEMS doctors on cars and helicopters a few minutes away. But I live in a remote area of the UK were distances b road to an incident is often greater than 30 minutes and then we have to call the HEMS unit out. Unlikely to happen down my neck of the woods.
 
rescue1 said:
Thoracotomy can be indicated in abdominal trauma, though it's not the best indication, purely for clamping the aorta in what would be REBOA zone 1 and knocking out all abdominal blood flow. You can't really control those bleeds with REBOA either because the celiac and SMA are superior to the renal arteries, and they're both in zone 2 anyway, which is (I don't know why) considered a no go zone for REBOA. REBOA you can clamp zone 1 or 3, and 3 maybe lets you control the IMA, but mostly the iliacs and below. A completely untested advantage is the ability to partially inflate the balloon and still try and allow some intestinal and renal blood flow, but I don't think anyone's actually studied how effective that could be.

Weirdly, one of the few "not recommended" indications for thoracotomy is blunt trauma with no signs of life, so I'm not sure why the above poster has that as an indication for HEMS, in addition to the fact that unless HEMS is on the initial dispatch it's probably too late anyway.
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Don't shoot the messenger - just relaying what those upstairs told me whats going to happen. Here is a recent paper citing a move away from penetrating chest trauma only for CST and adopting it for blunt trauma cardiac arrest. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098997/
 
Pond Life said:
Don't shoot the messenger - just relaying what those upstairs told me whats going to happen. Here is a recent paper citing a move away from penetrating chest trauma only for CST and adopting it for blunt trauma cardiac arrest. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098997/
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Oh that's pretty neat, I'll check it out.

Yeah I know it's not your fault, just like others have said it seems like a strange use of resources. But what do I know.
 
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