After Gunshots, the Fight to Save a Life

choi

Eric Curran, After Gunshots, the Fight to Save a Life. I want the violence to stop. I want Americans to see what it looks like. New York Times, Feb 17, 2019, at page SR4 in section SundayReview.
https://www.nytimes.com/2019/02/ ... ence-hospitals.html

2 and ½ consecutive paragraphs:

Trauma patients "are carried into ambulances and the back seats of police cars and rushed to a hospital. The emergency room nurses and doctors lift them onto stretchers. If they are awake, they may ask if they’re going to die. The doctor tells them no.

"Once inside, the trauma team yells out locations of holes in their body. The medical student tapes paper clips to each bullet wound so that they’re visible on X-ray. If the heart stops, doctors break through the sternum with a mallet and a chisel.

"Two gloved hands hold the heart and start to squeeze. More nurses and more doctors help inject medicines. They place paddles on the lifeless heart. * * *

My comment:
(a)
(i) SundayReview is published every Sunday, expressing viewpoints, This is the only time I read about medicine in this section, but this essay is about ruminations than medicine. The quotation is the only part about medicine. The online version has a photo caption that read, "When a patient's heart has stopped, handheld defibrillation paddles are placed directly onto the organ to shock it back to life. Sometimes a heartbeat returns. Often not."  Print does not have much space, so it ended at "back to life."
(ii) Back in Taiwan when I was there, this procedure is not something I heard of there. Then again there is not so manu gunshot or stab wounds there.
(iii) Defibrillation can be done with a portable "automated external defibrillator" (AED), external paddles (placed on chest wall; what you often see in televisions), and internal paddles (placed directly on heart).  (The handle is made of insulator.)

(b) Resuscitative Thoracotomy. YouTube.com, updated by Da7eee7 on July 13, 2017.
https://www.youtube.com/watch?v=r_mi16al05E

The female patient suffered from cardiac tamponade. So the doctor cut open pericardium 心包膜
https://en.wikipedia.org/wiki/Pericardium
to drain blood in pericardial space.
(i) In medicine, tamponade is always used in "cardiac tamponade" where heart is penetrated and blood from within it spills into pericardial space. In Normal condition, pericardial space is little.  With blood in the space, the heart can not dilate 00 thus unable to perform its function to pump blood.
(ii) tampon (n): from Modern-French noun masculine of the same spelling meaning plug.
https://www.etymonline.com/word/tampon

(c) Gretchen S Lent and Neel Kumar, Emergency Bedside Thoracotomy. Medscape, updated on Aug 7, 2017.
https://emedicine.medscape.com/article/82584-overview

Quote

"Since its introduction in 1900, the emergency department thoracotomy (EDT, sometimes referred to as emergency resuscitative thoracotomy) has been a subject of intense debate. It is a drastic, last-ditch effort to save the life of a patient in extremis due to injury. [1] Although some studies boast a 60% survival rate, others have argued that EDT is a futile and expensive procedure that only places health care providers at significant personal risk. Further, indications for EDT have widely varied. For these reasons, the EDT remains a controversial but potentially lifesaving procedure in a select group of patients.

"The primary goals of EDT include the following [4] :
• Hemorrhage control
• Release of cardiac tamponade
• Facilitation of internal/open cardiac massage
• Prevention of air embolism
• Exposure of the descending thoracic aorta for cross-clamping
• Repair cardiac or pulmonary injury

"Personal protective equipment [for healthcare [includes] Face shield

"Technique
* * *
A left-sided approach is made in all traumatic arrests and in patients with left-sided chest injuries, as shown below. (A right-sided approach may be used in nonarrested patients with right-sided injuries.)
* * *
Stop ventilation momentarily just before entering the pleural cavity to allow the lung to collapse and minimize iatrogenic injury.
* * *
Cross-clamping the descending aorta redistributes the available blood flow to the coronary and cerebral arteries.  Selective clamping of the descending aorta near the level of the diaphragm can also be used to control hemorrhage in abdominal vascular injuries.  Clamping distally is ideal because it maximizes spinal cord perfusion and because the aorta is relatively mobile at this location.
* * *
Organs that are distal to the aorta, including the bowel, kidneys, liver, and spinal cord, may become ischemic after occlusion.  Clamp time should be limited to 30 minutes or less. However, one study found that patients who underwent cross-clamping of the aorta for up to 60 minutes in emergency thoracotomy had no significant decrease in organ function. * * * There is evidence that a less traumatic intra-aortic balloon occlusion catheter can be used instead of traditional aortic cross-clamping  (resuscitative endovascular balloon occlusion of the aorta technique).
* * *
Perform internal cardiac massage with a 2-handed technique to avoid perforation of the ventricle with your thumb.  Compared with standard CPR, which delivers up to 20% of the cardiac output, internal CPR produces up to 55% of the body's baseline perfusion.
* * *
The pulmonary hilum may be cross-camped in cases of major pulmonary hemorrhage."

"Pearls
* * *
Control of the airway via standard orotracheal intubation technique is strongly advised prior to performing EDT. Selective intubation of the right mainstem bronchus is the preferred method. This allows for both ventilation and oxygenation of the patient via the right lung as well as decreased risk of injury to the left lung via decreased left lung expansion during a left-sided anterolateral thoracotomy. To intubate the right mainstem bronchus, directly visualize the vocal cords to pass the endotracheal (ET) tube into the trachea, and then blindly pass the ET tube to approximately 30 cm.
Either prior to EDT or while the procedure is being performed, an assistant should pass a nasogastric tube to help distinguish the esophagus from the aorta upon exploration of the thoracic contents [because when patient has low or no blood pressure, an aorta is hard to differentiate from an esophagus which are next to each other]."

(i) Both authors are MDs in the specialty of emergency medicine.
(ii) "Prevention of air embolism"

When there is a penetrating wound to the chest, it is possible that both long(s) and heart are penetrated, and that the air leaked from lung into chest cavity, and the through pericardial space into heart, causing air embolism (which may be fatal if air enters an artery supplying the brain.
(iii) "(A right-sided approach may be used in nonarrested patients with right-sided injuries.)"

The word "nonarrested" means there is no cardiac arrest. Naturally right-sided approach can be done if the penetrating wound extends from right chest to right side of the heart.  (In most people, a heart is positioned more to the left.)
(iv) "To intubate the right mainstem bronchus, directly visualize the vocal cords to pass the endotracheal (ET) tube into the trachea, and then blindly pass the ET tube to approximately 30 cm."

"The tube is more likely to enter the right main stem bronchus, due to its more vertical orientation" Malpositioned Endotracheal Tubes. School of Medicine, University of Virginia, undated.
(v) There is no need to read the rest.

(d) Of course, it is better to do all of this in an operation theater than in emergency room. But when a cardiac arrest accompanies a penetrating wound, EMT may have to do it in the field.