Open chest surgery is relatively common in the safe and sterile environment of a hospital. But GNAAS is taking the procedure into the pre-hospital environment. Here, doctor Chris Smith describes his role in the region’s first successful pre-hospital thoracotomy.
On August 9, 2017, a man was stabbed at Horden, County Durham. The man was bleeding to death from his wounds when GNAAS was called. The team included pilot Jay Steward, paramedic Tim West, and doctors David Driver and Chris Smith. What happened afterwards was a first for the region. Dr Smith took some time out from his busy schedule to describe the incident here.
How were you alerted to the incident?
We were actually flying, already in the air, and we were being sent to a car accident just off the A19. We were in flight when we heard that a young male had been stabbed and that the stabbing had occurred not far from where we were. So we were very lucky to be in flight when we got that call, and five minutes later we were told that the patient was in cardiac arrest.
We knew it was a very severe case. When patients like this are stabbed in the chest area, the heart can stop because the patient can bleed out, and we need to get there as quickly as possible to potentially do heart surgery at the roadside.
What happened when you arrived on scene?
We were very lucky in that we were able to land in a nearby park. We made our way to the scene. The young male had help already – there were some off duty nurses and police officers performing CPR and chest compressions. When we arrived there was quite a lot of blood on scene. The patient had no signs of life – he wasn’t breathing, there was no eye movement and we couldn’t feel a pulse either, so we knew the patient was in cardiac arrest. From that moment we’ve got very limited time to be able to do what we need to do.
Why would a thoracotomy make a difference?
The patient needs surgery to stop that bleeding in the shortest time possible. Normally that patient would be transported to hospital which in this case could have taken around half an hour or 35 minutes – he would continue to be in cardiac arrest and would arrive in the accident and emergency department in cardiac arrest and probably be pronounced dead. But if we’re able to do that surgery quickly, at the time when it is needed, and to stop that bleeding, we can hopefully restart the heart and give further blood and blood products on scene and give that patient the best possible chance of life.
How does it work?
The procedure is relatively severe. The first thing we need to identify is whether the heart is moving or not. So we use an ultrasound scanner, a very small piece of equipment, which can look inside the chest and see the heart. We need to identify if there are any signs of life or not – is there any heartbeat and pulse, and if not we know we need to get inside the chest and do that surgery. We are in a public place so we need to be aware of the people around us. So part of that is using blankets and screens to provide an area that’s more private so we’re able to do what we need to do. It is quite gruesome, it is quite graphic, but it needs to be done.
We practice it as a daily occurrence. All our teams are able to do this procedure. It’s something that is at the forefront of our mind. It’s a capability that we’ve rehearsed to use within the service. It is difficult to make that decision, but we’ve got to look at the patient in front of us and realise that effectively they are dead and the only chance they’ve got is us doing what we do at that moment in time.
The procedure involves making two small holes either side of the chest, letting out any air that might be there. At that point the patient may return to life, they may have a heartbeat and a pulse and that’s something that we check again at this point. If that’s not the case we need to make a big incision right the way across the chest and cut through the muscle, expose the chest so we can get access to the heart and lungs, identify what’s bleeding and try and stop that in any way we can, and try and release that clot that has probably formed around the heart itself. By doing that, the heart can start to beat again, especially if we are able to give blood products through the big veins in the body. So it’s a technical procedure, the decision is quite instantaneous, and it can be quite complicated but we try to make it as simple as possible so all our teams can do it on any given day.
In the case of most people who have been stabbed to the chest, in any area around the heart, there’s a small layer of tissue that covers the heart called the pericardium that can fill with blood and if that happens it stops the heart from beating. We found that in this case. We dissected that layer, removed the clot and tried to identify any other bleeding points. And then it’s just a case of clamping down those areas, whether it’s a lung or a vessel, putting your finger on it, stopping that bleeding, effectively turning off the tap, restoring that heartbeat, and potentially do an internal massage with your hands, and then giving blood products to fill the heart back up to make it beat and to allow the heart to basically pump blood to the brain and keep the brain alive.
We did a small amount of cardiac massage but luckily we were there so quickly that the patient didn’t need a huge amount of massage and we were able to get the heart beating fairly quickly, which is a good sign.
What happened then?
We had practiced the logistics of moving a patient who had undergone this complex procedure a few weeks beforehand using a manikin in the aircraft. So we were confident we could fly him to the major trauma centre. We flew him to Middlesbrough and thankfully his heart carried on beating – all the observations and numbers were good and we were able to hand him over to a cardio-thoracic surgeon in Middlesbrough who took over his care, who took him straight to theatre, was able to do a bit more complicated surgery, was able to warm him up, and all the nurses and doctors on the ICU then looked after him for quite a long time until he thankfully made a really good recovery.
How do you reflect on the incident now?
It’s probably the best feeling we can hope for as doctors and paramedics. We’re always hoping to have a survivor from a procedure like this. I think it’s proof that if everything works in terms of the patient getting good care on scene straight away, if we can utilise the aircraft or the car and get the team to the scene as quickly as possible, then we can make a difference to that patient.
Everyone who was on scene played a part – from the police officers who were helping holding screens to the paramedics at the North East Ambulance Service who were managing the patient’s airway to the off duty nurses who provided CPR before we arrived – every single person made a difference that day.
We were lucky in this case from the moment the 999 call was made it was identified by our operations desk, we were there very quickly, and everything lined up to create an unexpected survivor. I’m fairly confident from my previous experience and seeing these patients coming in to the accident and emergency department in that state after 30 minutes in the back of an ambulance, then he would have died. I’m just glad we could be there that day.
I think it’s the whole suite of skills that we have got – whether it’s from the aircraft or car – to carrying blood products, to using the ultrasound monitor, to training our teams to perform this procedure on any given day. Thankfully, GNAAS critical care teams have the training and equipment necessary to do this at any moment and the people of the North East and North West have thankfully got us there to do that through their ongoing support.
19:00 Mobile to incident
19:15 On scene, treatment commences
19:40 Patient airlifted
19:49 Arrive at hospital in Middlesbrough
20:20 Arrived back at base
This story was shared with the backing of the patient and his family. GNAAS would like to thank them for their support.