Who should perform prehospital thoracotomy?
The Norwegian Society of Anaesthesiology has taken the initiative to draw up national guidelines for prehospital thoracotomy. In their consultative submission, the National Advisory Unit on Traumatology and the Norwegian Surgical Association maintain that the need for the procedure is too limited to justify training in and a focus on this procedure. They are concerned that the procedure might be carried out on patients who could have survived with rapid transport to hospital, and that the risk factors associated with prehospital thoracotomy are made light of.
A knife wound or other penetrating injury to the heart is rare, but in our view frequency is not an argument for failing to use a potentially life-saving procedure. In our prehospital service we are committed to providing necessary medical aid to all, irrespective of the incidence of the condition and the prognosis. In a meaningful discussion of prehospital thoracotomy, it must be assumed that experienced anaesthetists comply conscientiously with the indication for the procedure and possess the necessary expertise to determine whether the patient is without circulation. Prehospitally, we constantly having to address clinical challenges that we have been trained to deal with, while focusing simultaneously on bringing the patient as fast as possible to the correct treatment level.
The trauma surgery milieu has defined the limits for appropriate use of resuscitative thoracotomy in hospitals. This delimitation is well-founded and supported by repeated observational studies from different countries and trauma systems (1, 2, 7, 8, 13). Direct transport to hospital is only appropriate in a situation where it is believed that the procedure can be performed inside the hospital within ten minutes of circulatory arrest (4, 9, 13). The question of which specialist group performs the procedure is secondary to the time aspect. The real risk lies in transporting these patients during ongoing CPR, and then performing the procedure outside the time limit that offers a chance of survival. Patients who meet the criteria for prehospital resuscitative thoracotomy do not have any real treatment alternative.
The London Air Ambulance Service has over 20 years of experience of performing prehospital thoracotomy, and in a health service that resembles ours in many ways, anaesthetists have demonstrated that they can perform a procedure of this nature safely and effectively (13). We acknowledge that a successfully performed procedure and restored circulation still leaves a highly demanding situation with respect to haemorrhage control and further stabilisation, but this scenario is preferable to the alternative.