ED thoracotomy is performed infrequently, under high stress circumstances, and with high stakes for the victim. Thus, it is a setup for mayhem. If not conducted properly, it can be noisy, disorganized, and dangerous due to the possibility of blood exposure. Unfortunately, we don’t know where these trauma patients have been. Previous data shows that the incidence of HIV, hepatitis, and other infectious agents is low but significant.
Occupational exposure of healthcare providers to these infectious agents via needlestick/cut, mucus membrane, open wound, or eyes can happen during any surgical procedure. But the possibility during the less controlled ED thoracotomy would seem to be greater. So the group at the University of Pennsylvania decided to perform a prospective, observational study at 16 trauma centers over a 2 year period. A total of 1360 participants were surveyed who were involved in 305 ED thoracotomies. They analyzed the data for risk of occupational exposure.
Here are the factoids:
- Mechanism was 68% gunshot, 57% were undergoing prehospital CPR, and 37% arrived with signs of life
- 22 exposures were documented, or a rate of 7% per thoracotomy and 1% per participant
- There was no difference between Level I and II centers or hours worked at time of procedure
- Those with exposures were typically trainees (68%) who sustained a percutaneous injury (86%) during the actual procedure (73%)
- Full personal protective precautions were only utilized by 46% of exposed providers (!!)
- Each additional piece of personal protective equipment reduced the risk of exposure by 32%
Bottom line: The authors concluded that the incidence of exposure to patient blood is the same as for other operative procedures. Hmm. They also state that the fear of occupational exposure should not deter providers from performing thoracotomy.
I certainly agree that one should always follow the accepted indications for performing ED thoracotomy. I’m not so sure about the comparison with non-emergent procedures, since the numbers are fairly low. However, of one thing there is no doubt: wear your personal protective equipment! You never know when you might be exposed!
Here are some questions for the authors to consider before their presentation:
- What kind of power analysis did you do to ensure that you could draw reasonable comparisons between thoracotomy and non-emergent procedures?
- Please provide detailed breakdown of how you sliced and diced your numbers in terms of type of provider, hours worked, trainee level, precautions taken, etc
- I enjoyed this paper and look forward to hearing the details!