Performing an emergency thoracotomy on the street is very different than doing it in an operating room.

In the operating room, the surgeon has a clearer understanding of the type of intra thoracic tension involved, whether due to trapped blood (hemothorax), trapped air (pneumothorax), or both and also, he has the proper instruments to incise and enter the chest cavity without causing further injury of surrounding tissue.

The best approach in the event of this type of emergency is call the emergency but unfortunately do nothing unless you have a large canula to decompress the chest through a thoracentesis.

 Incising the chest with a utility knife will create an open pneumothorax in the presence of a closed hemothorax.

With a hemothorax, blood collects inside the cavity, creating positive pressure that compresses other organs, compromising blood flow and preventing organs from expanding and contracting properly in this case, the heart muscle and the lungs.

In the case of a pneumothorax, the type of emergency is similar to that of a hemothorax, except the patient experiences hypoxemia at a faster rate, as trapped air compresses in a faster rate surrounding tissue and organs near the injury.

In the television series “The Good Doctor,” when Dr. Shaun performed the tube thoracotomy, He used a 2 cm of diameter hose to bleed the air that was trapped outside the lung, which he inserted in the space between the second and third rib.

For the puncture incision, Dr. Shaun used a utility knife, which is approximately 1.5 cm wide and has a tip angle of approximately 45 degrees, which is too wide with a sharp end similar to that of a trocar.  This would have created further injury than what was expected.

Prior to his incision, he poured whiskey over the hose he was going to insert later and to decontaminate the incision site.

The debate is about what is clinically appropriate in terms of sterility to prevent infection using alcohol pre-surgically and vasodilating the surgical area.

In the operating room, surgeons typically use a 15 blade, which is about 0.5 cm wide, to make the intercostal incision. However, if I was the first responder on the street, I would not waste time with a blade and find a canula to perform an emergency thoracentesis instead, as it is much safer in the event a pneumothorax is misdiagnosed for a hemothorax. 

In the operating room, I would prefer using a 10 blade, as it allows for a wider cut, reaching 4 cm deep into the pleura, thus eliminating the need for blunt dissection after the initial cut with a 15 blade.

Using a utility knife for this type of emergency is nearly impossible. The incision would need to be about 4 centimeters into the outer layer of the pleural space without puncturing the lung or lacerating the intercostal vein located closed to each rib. Therefore, the incision should be made sagittal not transversal in the same manner a trocar be used to puncture the abdomen for a laparoscopic procedure.

Initially, Dr. Shaun diagnosed a left pneumothorax, which is puzzling given that both injuries occurred on the right side of the neck and chest. If the sharp object had indeed penetrated the right external jugular vein, it would have traveled down to the right subclavian vein, into the brachiocephalic, and ending up in the superior vena cava and right atrium of the heart. At this point, the sharp object would have caused a cardiac tamponade on the right side of the heart, not the left. If the object had continued its path, it would have exited into the right ventricle and then into the pulmonary artery, which carries deoxygenated blood to the left lung and back to the left atrium. This cardiac tamponade would have led to a collapse of the pulmonary veins, which carry oxygenated blood back into the left atrium of the heart

Dr. Shaun did examine both antecubital fossae for venous distension to diagnose a possible hemothorax or cardiac tamponade. However, his findings indicated a left venous distension, therefore reaching a diagnosis of left pneumothorax rather than left hemothorax.  He came to this conclusion based on the type of object that penetrated the chest, which ruled out a glass puncture injury in the right aspect of the torso.

Had this been a true emergency, the patient would have suffered a brain injury even before the thoracotomy was attempted.

The Good Doctor, emergency tube thoracotomy explained