i got to experience this at bedside while working in the ED. gsw to left armpit. they gave the pt over 30 transfusions total, i got to do chest compressions in OR while they were getting into his belly. it was wild. thought forsure the pt was a gonner.... ended up in stepdown two weeks later following commands. idk what happened after that but i know he survived!
Wow Professor Larry, your expertise and calmness to guide the resus team was amazing here. Was this a case of rupture aorta and did the patient survive?
This was incredible to watch, I was rooting everyone on and hoping the trauma patient would pull through. I'm sorry for your loss, the gentleman's family and the medical team as they are completely invested in their patient's outcome.
I will never stop being in awe of those who work in emergency medicine. This level of skill and stress management and effort is incredible and I'm so thankful that all these people exist.
As they say "Teamwork is Dreamwork" and it is absolutely true. This is not a job for a surgical resident and a couple of nurses. There is so much need for simultaneous actions on the part of the team to be successful in the outcome. Another great educational video for your collection. Well done.
What are the indications for this, Doc? It seems like so many things can do wrong and there’s such a high likelihood for damage to chest cavity structures. I’m assuming it’s really only saved for massive aortic hemorrhage or other severe thoracic or abdominal hemorrhage? I’m a paramedic and would love to learn more. edit: had a patient today that would’ve been a perfect candidate for this, GSW to just left of the sternum at the 3rd intercostal. unfortunately we were too far from the trauma center for transport in arrest to be reasonable and he expired.
Very few indications. And some of them controversial. Penetrating chest trauma with witnessed loss of vital signs. Cardiac trauma sometimes. Blunt arrest mortality in thoracotomies is like 100%. in penetrating chest trauma like 10% survive. It's basically a last ditch effort.
Ultimately it was likely due to blood loss. This was a case of severe blunt force trauma to the chest and abdomen, via a motorcycle accident. There were likely too many bleeders to deal with and the fluids/blood that was transfused ultimately was unable to sustain life sustaining blood pressure and heart rhythm. Edited to add information.
@@lispyDribbler I actually believe he made it an hour-ish into the operating room before succumbing. There was just too much trauma to internal organs. Obviously the heart, but also the lungs, the diaphragm, liver, spleen, kidneys etc. Between the time he crashed, and first responders arrived he already would have internally bled a significant amount, then there's the time EMS does their best to stabilize at the scene, time to travel to trauma center and then time for procedures, it was just too much damage with too much time in between steps for proper damage control. It's an unfortunate situation, and I give pause and send well wishes to the family of the departed.
Dr. Mellick, true story. This was back in the 1950s. My grandparents operated a funeral home. My father did have a funeral directors license and was embalming someone. I peeked around the corner and vividly remember seeing inside the chest cavity. There were no internal organs and I asked my dad where they were and he said they were in a bucket. True or false who knows. I guess I should have been traumatized, but I don't remember any ill effects. I never had any desire for that kind of work and worked in a big manufacturing facility. I must of been 6 or 7 years old at the time. I can watch this but I couldn't do it.
Yes, I am reworking older videos for the Roberts and Hedges Emergency Procedures textbook and plan to simply upgrade educationally some of the other videos.
Patient did not survive. He had reestablished cardiac activity and was rushed to an operating theatre where he ultimately succumbed to the injuries. Edited to add information.
Survival rates for blunt trauma cardiac arrests are very low. In general survival is reported at 7 to 8 percent (higher in some settings), but lower for blunt trauma arrests.
Thanks for the statistics Dr. Mellick. Great example as well. Thanks for your time and service, both within the medical field but on youtube as well. @@lmellick
This was blunt trauma, not penetrating trauma. I didn’t think an open thoracotomy was indicated for blunt trauma, unless, perhaps he lost his vital signs in the ER. Did he have bilateral chest tubes, and was a blind pericardial tap attempted in the subxyphoid space shooting for the tip of the left scapula,? Did the patient live?
Because it happened in the distant past (video remake for a textbook) I don't remember all of the circumstances, but his vital signs were lost shortly before or at the time of arrival in the ED. Pericardial taps in trauma are rarely helpful and will simply delay a life-saving procedure. Any unnecessary delays on this procedure will decrease your chances of success.
@@lmellickI found the original video and read the description box. According to your description, the patient in this video sustained multiple blunt force injuries as a result of a motorcycle accident. The thoracotomy was done in the ED and the patient was brought to the OR and succumbed to his injuries while in surgery.
It's only in the USA where it is taught that open thoracotomy isn't indicated for blunt trauma. In the UK, their emergency physicians perform open thoracotomies prehospitally on blunt traumatic arrests often and have people survive regularly. They're able to cross clamp the aorta in the setting of major abdominal hemorrhage and give blood restoring vital signs. They started doing it prehospital in the 90s. Consider viewing the series "an hour to save your life" where there are episodes showing prehospital thoracotomy.
If a blunt trauma patient(without severe head injuries or injuries incompatible with life) loses a pulse and they are within 10 minutes of a level I or II trauma center then a thoracotomy is indicated. I've had several patients in cardiac arrest from blunt trauma who survived but they all had a few things in common. They all were without a pulse for under 10 minutes prior to arriving to the ER, they all had positive EFAST exams, and all had survivable injuries/conditions including tension pneumothorax, hemothorax, cardiac tamponade, abdominal or thoracic injuries that could be treated with packing, ligation, cautery, and or fixing any defects/injuries in the different areas of the heart like the right ventricle.
Does anybody know what happened like? Why did this procedure have to happen? What happened to the man? Thank you so crazy this procedure it's amazing what these doctors do
The patient experienced severe blunt force trauma subsequent to a motorcycle accident. Upon arrival to the trauma center, the attending physician would have had multiple modalities and specialties acting and it would have very quickly become apparent that the patient was bleeding internally, especially near the heart and lungs. Thus an emergency thoracotomy would have been decided as the most prudent course of action to evacuate the blood already in the chest cavity, but to also find and clamp bleeding arteries to stabilize the patient enough for transportation to the operating room. It was during the operation that the patient ultimately succumbed to his injuries despite all of these extraordinary measures.
He would have been unconscious. As a fellow commenter below, @Ro-dent said, the patient was intubated, which would have required sedation. My initial statement of he was unconscious stands, but I wanted to edit my comment to reflect upon what @Ro-dent reminded me of. So props to him for the reminder and I have amended my comment to reflect that. Edited to add new information.
@@lispyDribblerThat is a good point, and you are right. He would not have been aware of anything going on. He may also have suffered brain damage as well, it's unclear. But you are right, he would have been sedated to allow for intubation, as well as to allow the team to work without a screaming or writhing/flailing patient as they make very deep incisions and utilize a lot of blunt instruments. Point being it would be excruciatingly painful to be concious for this kind of procedure. Thank you for the correction, and I will amend my previous comment to reflect that.
i got to experience this at bedside while working in the ED. gsw to left armpit. they gave the pt over 30 transfusions total, i got to do chest compressions in OR while they were getting into his belly. it was wild. thought forsure the pt was a gonner.... ended up in stepdown two weeks later following commands. idk what happened after that but i know he survived!
That was as terrifying as it was amazing! 😮
wow
Wow Professor Larry, your expertise and calmness to guide the resus team was amazing here. Was this a case of rupture aorta and did the patient survive?
The patient did not survive. Initially cardiac activity was reestablished but the patient passed on the operating table a couple hours later.
Not a ruptured aorta but his injuries were significant enough that he died in the operating room.
This is WILD!!! Your educational videos are out of this world! Thank you for sharing with the world what goes on in trauma medicine.
You are welcome!
Thank you Doc. You rock 🪨
This was incredible to watch, I was rooting everyone on and hoping the trauma patient would pull through. I'm sorry for your loss, the gentleman's family and the medical team as they are completely invested in their patient's outcome.
Thanks!
I will never stop being in awe of those who work in emergency medicine. This level of skill and stress management and effort is incredible and I'm so thankful that all these people exist.
Thank you!
As they say "Teamwork is Dreamwork" and it is absolutely true. This is not a job for a surgical resident and a couple of nurses. There is so much need for simultaneous actions on the part of the team to be successful in the outcome. Another great educational video for your collection. Well done.
Thank you!
Big fan of your work in making education accessible Dr. Mellick thank you for all you do keep it up!
Thank you!!
I’m a pre med grad student, aspiring to be an EM doc. Your channels is so awesome, and such an inspiration
I'm so glad!
A great demonstration. One hopes the gentleman yet lives! Thank you, Doc!
Thank you!
What are the indications for this, Doc? It seems like so many things can do wrong and there’s such a high likelihood for damage to chest cavity structures. I’m assuming it’s really only saved for massive aortic hemorrhage or other severe thoracic or abdominal hemorrhage? I’m a paramedic and would love to learn more.
edit: had a patient today that would’ve been a perfect candidate for this, GSW to just left of the sternum at the 3rd intercostal. unfortunately we were too far from the trauma center for transport in arrest to be reasonable and he expired.
Very few indications. And some of them controversial. Penetrating chest trauma with witnessed loss of vital signs. Cardiac trauma sometimes. Blunt arrest mortality in thoracotomies is like 100%. in penetrating chest trauma like 10% survive. It's basically a last ditch effort.
Mainly for blood compressing the heart
An oldie with a new explanation! Thank you!
Yes, I am reworking videos for the Roberts and Hedges emergency procedures textbook to use. You are welcome.
I seen in the comment the man passed away. Does anybody know why he passed away? Like? Why couldn't they fix it? Just curious, thank you.
Ultimately it was likely due to blood loss. This was a case of severe blunt force trauma to the chest and abdomen, via a motorcycle accident. There were likely too many bleeders to deal with and the fluids/blood that was transfused ultimately was unable to sustain life sustaining blood pressure and heart rhythm.
Edited to add information.
@@lispyDribbler I actually believe he made it an hour-ish into the operating room before succumbing. There was just too much trauma to internal organs. Obviously the heart, but also the lungs, the diaphragm, liver, spleen, kidneys etc. Between the time he crashed, and first responders arrived he already would have internally bled a significant amount, then there's the time EMS does their best to stabilize at the scene, time to travel to trauma center and then time for procedures, it was just too much damage with too much time in between steps for proper damage control. It's an unfortunate situation, and I give pause and send well wishes to the family of the departed.
@@vkov0the golden hour on steroids
Heart stopped beating
Dr. Mellick, true story. This was back in the 1950s. My grandparents operated a funeral home. My father did have a funeral directors license and was embalming someone. I peeked around the corner and vividly remember seeing inside the chest cavity. There were no internal organs and I asked my dad where they were and he said they were in a bucket. True or false who knows. I guess I should have been traumatized, but I don't remember any ill effects. I never had any desire for that kind of work and worked in a big manufacturing facility. I must of been 6 or 7 years old at the time. I can watch this but I couldn't do it.
Thanks! My kids have a major problem with videos like this one.
@@lmellick I appreciate that you took the time to read and reply to me. Your patients are fortunate to have you as their physician. Stay safe.
Larry, is this from a few years back, gun shot wound, think this is the first video I saw of yours, amazing to see the team working to save a life
Yes, I am reworking older videos for the Roberts and Hedges Emergency Procedures textbook and plan to simply upgrade educationally some of the other videos.
@@lmellick Larry, is there a book coming out
Not from me, but the next edition of the emergency procedures textbook will have a huge number of my videos. Hope you are doing well.@@johndevitt2164
@lmellick let me know when it's out maybe I can order a copy, would you sign it?
BTW, if there is a video in the collection on applying a chest decompression needle for a pneumothorax, if possible, would be great to see
My advance directive specifically opts me out of this procedure
I can understand!
Thank you for fantastic video, what are the odds of being successfull and did patient survive?
Thank you doc.
Patient did not survive. He had reestablished cardiac activity and was rushed to an operating theatre where he ultimately succumbed to the injuries.
Edited to add information.
Survival rates for blunt trauma cardiac arrests are very low. In general survival is reported at 7 to 8 percent (higher in some settings), but lower for blunt trauma arrests.
Thanks for the statistics Dr. Mellick. Great example as well. Thanks for your time and service, both within the medical field but on youtube as well. @@lmellick
Thank you for your kind words! Much appreciated.@@vkov0
stuff like this is wild and awesome and why i love emergency medicine
That was one crowded work area! Great work as always.
Thanks!
This was blunt trauma, not penetrating trauma. I didn’t think an open thoracotomy was indicated for blunt trauma, unless, perhaps he lost his vital signs in the ER.
Did he have bilateral chest tubes, and was a blind pericardial tap attempted in the subxyphoid space shooting for the tip of the left scapula,?
Did the patient live?
Because it happened in the distant past (video remake for a textbook) I don't remember all of the circumstances, but his vital signs were lost shortly before or at the time of arrival in the ED. Pericardial taps in trauma are rarely helpful and will simply delay a life-saving procedure. Any unnecessary delays on this procedure will decrease your chances of success.
Thank You. @@lmellick
@@lmellickI found the original video and read the description box. According to your description, the patient in this video sustained multiple blunt force injuries as a result of a motorcycle accident. The thoracotomy was done in the ED and the patient was brought to the OR and succumbed to his injuries while in surgery.
It's only in the USA where it is taught that open thoracotomy isn't indicated for blunt trauma. In the UK, their emergency physicians perform open thoracotomies prehospitally on blunt traumatic arrests often and have people survive regularly. They're able to cross clamp the aorta in the setting of major abdominal hemorrhage and give blood restoring vital signs. They started doing it prehospital in the 90s. Consider viewing the series "an hour to save your life" where there are episodes showing prehospital thoracotomy.
If a blunt trauma patient(without severe head injuries or injuries incompatible with life) loses a pulse and they are within 10 minutes of a level I or II trauma center then a thoracotomy is indicated. I've had several patients in cardiac arrest from blunt trauma who survived but they all had a few things in common. They all were without a pulse for under 10 minutes prior to arriving to the ER, they all had positive EFAST exams, and all had survivable injuries/conditions including tension pneumothorax, hemothorax, cardiac tamponade, abdominal or thoracic injuries that could be treated with packing, ligation, cautery, and or fixing any defects/injuries in the different areas of the heart like the right ventricle.
Does anybody know what happened like? Why did this procedure have to happen? What happened to the man? Thank you so crazy this procedure it's amazing what these doctors do
The patient experienced severe blunt force trauma subsequent to a motorcycle accident. Upon arrival to the trauma center, the attending physician would have had multiple modalities and specialties acting and it would have very quickly become apparent that the patient was bleeding internally, especially near the heart and lungs. Thus an emergency thoracotomy would have been decided as the most prudent course of action to evacuate the blood already in the chest cavity, but to also find and clamp bleeding arteries to stabilize the patient enough for transportation to the operating room. It was during the operation that the patient ultimately succumbed to his injuries despite all of these extraordinary measures.
@@vkov0 Thank you so much
Does it ever work?
Yes, it does. Not high percentages, but enough to make it worthwhile.
awesome
What a great video
Thank you!
Got it
Awesome video for a soon to be surgery intern! Thanks for sharing
You are welcome.
You are Gods on earth! ❤
No, no, no! Far from it! But thanks for the kind words!
Was he awake or asleep
He would have been unconscious. As a fellow commenter below, @Ro-dent said, the patient was intubated, which would have required sedation. My initial statement of he was unconscious stands, but I wanted to edit my comment to reflect upon what @Ro-dent reminded me of. So props to him for the reminder and I have amended my comment to reflect that.
Edited to add new information.
@@lispyDribblerThat is a good point, and you are right.
He would not have been aware of anything going on. He may also have suffered brain damage as well, it's unclear. But you are right, he would have been sedated to allow for intubation, as well as to allow the team to work without a screaming or writhing/flailing patient as they make very deep incisions and utilize a lot of blunt instruments. Point being it would be excruciatingly painful to be concious for this kind of procedure.
Thank you for the correction, and I will amend my previous comment to reflect that.
Would you not stop cpr prior to attempting this?
Yes, this is a dangerous procedure for the operators.