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6.6 What's this rib spreader thing, and what's a thoracotomy? (ER)




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This article is from the ER FAQ, by Rose Cooper cooper@acm.cse.msu.edu with numerous contributions by others.

6.6 What's this rib spreader thing, and what's a thoracotomy? (ER)

There's a really cool and incredibly gory picture of one in action at
<http://www.swsahs.nsw.gov.au/livtrauma/education/surgery/cardiac.asp>.
It's far more graphic than anything you're going to see on TV, with the
possible exception of stuff on another TLC program that shall remain
nameless because some people I know are very angry at it right now.
(Subliminal hint: It features operations). I probably could have opened a
chest kit, taken the thing out, put it on a drape and taken a picture, but
it's much more fun to actually see one in action, don't you think?

For people who are easily offended and don't want to be grossed out, or
who think they may easily lose their lunches, think about what you might see
if you look at the above referenced picture, which demonstrates the operative
repair of a ventricular stab wound. It's sort of what you might have seen
from a better angle during the closing moments of the fourth season finale
when Doug and Mark were working that kid. In terms of gore-factor, think
about where the heart is in relation to the rest of the body and what you'd
have to do to get access to the heart.

Yeah. Exactly.

A rib spreader is pretty much what the name implies -- it's a thing you
use to...uh...spread the ribs. In the picture, it's that thing holding the
operative site open, and yes, if you think it looks like it belongs at your
local garage instead of at the hospital, you're not alone. They make a really
interesting noise that I'll never quite be able to forget when you start
cranking -- it's the sound of ribs breaking, and it's not unlike the first
time you do CPR on someone and hear their ribs break. I don't know whether or
not the fact they haven't played it on ER yet is a good thing or a bad thing.

Anyway, there seems to be something of a running joke on ER: at least
once an episode, someone mentions a rib spreader or asks for it. This is of
specific relevance to emergency medicine, because the rib spreader is a
crucial instrument in what has long been considered our "dramatic as hell"
procedure -- the thoracotomy.

A thoracotomy is usually performed in a traumatic arrest (cardiac arrest
with a history of trauma, generally penetrating) to gain access to the heart
and great vessels. During this time, you can repair lacerations to the heart
muscle, relieve pericardial tamponade (build-up of fluid in the sac that
surrounds the heart), and also clamp the descending aorta off to control
bleeding below the diaphragm. There's a lot of controversy over how and where
this should be performed, and once it is done, the mortality goes through the
roof. (I should point out right here that traumatic arrests have a horrible
prognosis anyway; penetrating trauma with accompanying arrest and no signs
of life in the field have a virtually zero chance of survival. There's one
case I know of where such a patient survived, but he was hit by a car
literally in front of the hospital, and a paramedic unit happened to be right
there.) There are lots of jokes about thoracotomies, including my favourite,
by Paul Pepe: "The indication for a thoracotomy [at Ben Taub General
Hospital, in Houston] is the inability to refuse it." Dr. Pepe wrote an
article a couple years back about one of his colleagues doing on in the
back of an ambulance (which is in itself interesting, since thoracotomies
require immediate definitive surgical care, but that's not the incredible
part: the patient lived), and he's got a bit of a reputation as being a fan
of the procedure. I should point out this won't happen to you unless something
is really wrong, in the incredibly unlikely event that wasn't immediately
obvious. :)

 

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