Emergency Centre Thoracotomy in South Africa.

Background

I was so pleased to see this paper from a team including a great friend of the podcast, Dr Katya Evans at Mitchell’s Plain hospital in Cape Town. I’ve been lucky enough to visit Kat and her husband Craig several times and it’s truly inspirational what they do in emergency and prehospital care. You can read more about that here. I remember being amazed at just how much penetrating trauma they see, and cope with, and yet they are not a level 1 trauma centre (though they see far more trauma than I do in a level 1 centre in the UK). This paper puts together their experience of thoracotomy for penetrating injury and the quite remarkably high rate of success. This, together with the recent paper from London Air Ambulance really bring forward our understanding of emergency thoracotomy.

Resuscitative thoracotomy is usually described in the context of Level 1 trauma centres, or in enhanced pre-hospital care teams. The procedure is certainly a challenge, which can be overcome by training, but it often has poor outcomes in hospital practice.. In the UK, all trauma units (not just trauma centres) are supposed to be able to do the procedure, but training and capability are patchy. You might think that if you tried to do this in a. resource-limited setting with no ICU, no onsite blood bank, and a workforce comprising mostly junior clinicians then the outcomes would be terrible, but are they?

That’s exactly the scenario explored by Sittmann and colleagues in their 2025 study of Emergency Centre Thoracotomy (ECT) in two district-level emergency centres in Cape Town, South Africa. The abstract is below, but as always we want you to go and read the full paper yourself.

Abstract

Introduction: Trauma is a major contributor to global disease burden, disproportionally affecting low- and middle-income countries, especially in the African Region. Emergency centre thoracotomy (ECT) is a potentially life-saving procedure for a sub-group of trauma patients in extremis. Most literature regarding ECT originated in high-income countries. This study aimed to describe patient, procedure and outcome characteristics of ECTs performed at two facilities in a resource-limited setting in South Africa.

Patients and methods: A retrospective chart review was performed at two district-level facilities in Cape Town from 1 April 2017 to 31 March 2021. All patients who underwent post-trauma thoracotomy in the emergency centre (EC) were eligible for inclusion. Cases were excluded if patients did not undergo thoracotomy in the EC, or if medical records were missing. Patients were identified using an electronic EC attendance register, and theatre records, which were screened using documented diagnoses and dispositions. Clinical notes were interrogated for information regarding patient demographics, mechanism of injury, clinical presentation, procedural characteristics (such as level of clinician, injury found, use of ultrasound). Outcomes measured were survival to specified endpoints, and neurological or functional outcomes.

Results: Over 4 years, 67 ECTs were performed (50 stabs, 17 gunshots). No ECTs were performed for blunt trauma. Most patients were male, with a median age of 25 years (IQR 21-33). More than two-thirds of patients presented with their own transport, and more than 80 % presented with signs of life. Most ECTs were performed by non-specialists. Survival to hospital discharge was 24 % (32 % for stabs, 0 % for gunshots). Neurological outcome was difficult to analyse, however seemed to be good in all but one survivor.

Conclusion: The performance of ECT in this resource-limited district-level setting, followed by stabilisation and transfer of patients to tertiary hospitals seems to result in comparable or better survival rates than reported in international literature. Further research is needed to better describe the performance and outcomes of EC thoracotomies in a resource-limited setting. This study setting, with high incidence of trauma and ECT performed, provides an excellent opportunity for further research. Prospective studies may demonstrate correlations between specific patient and procedural characteristics and outcomes and may guide the development of local guidelines.

What kind of study is this?

This is a retrospective descriptive study spanning four years, from April 2017 to March 2021. It was conducted at Mitchells Plain Hospital and Heideveld Emergency Centre, two district-level facilities serving the Cape Flats — an area characterised by high rates of interpersonal and gang-related violence. I’ve visited both of these units and they are not that big. Heideveld in particular is (as I remember it) almost a stand alone emergency care centre. It’s a long way away from an MTC in the UK.

This is a retrospective study, and we do need to be cautious about that. Retrospective studies rely on chart reviews, using local electronic tracking systems and theatre records to identify eligible cases. Inevitably this can lead to omissions and some bias in the findings.

Inclusion was simple: all patients who had a thoracotomy in the emergency centre during the study period. Exclusion criteria were equally straightforward — patients without complete records or those who underwent thoracotomy outside of the EC were not included.

It’s a pragmatic, observational study, not disimilar to the LAA studyt, but clearly in a very different setting and health economy.

Tell me about the patients

Over four years, the authors identified 67 patients who underwent ECT. That’s a a huge number as comoared to UK practice, more than we see in an MTC, and more than Ive done in my entire career.

The median age was 25 (IQR 21–33), and 97% were male. About one in five were under 18. Our age range in the UK is older and thankfully we have fewer kids, although sadly we do have a few coming to the Paeds ED.

All patients had sustained penetrating trauma — 75% were stabs and 25% gunshot wounds (GSWs). Notably, there were no ECTs performed for blunt trauma during the study period. Over half had single thoracic injuries, and most arrived at the hospital outside of office hours, typically by private transport rather than ambulance. In fact, only 28% were brought in by Emergency Medical Services (EMS).

Physiologically, two-thirds had a palpable pulse on arrival, 21% were pulseless but with other signs of life, and 7% had no signs of life at all. This is important as for most emergency physicians the role of the ED thoracotomy is for those who are pulseless, so it is a different cohort to those that I might perform a thoracotomy on in the ED, although aqs we havbe previously discussed my group of patients in whom thoracotomy is indicated is not just those who are dead, but also those who are nearly dead (a definite shift in practice based onthe LAA data).

What were the measured outcomes in this study?

The outcomes were paragmatic and simple.

Survival to exit from the emergency centre
Survival to transfer (where applicable)
24-hour survival
Survival to hospital discharge

Neurological and functional outcomes at discharge were also reviewed, though with limited consistency in the documentation.

What are the main results?

Overall survival to hospital discharge was 24% (n=16)
- 32% for stab wounds
- 0% for gunshot wounds
46% survived to EC exit
31% survived 24 hours

Of those who survived to discharge, 15 of the 16 appeared to have good neurological recovery — 12 had documented GCS 15/15 and were mobilising independently, and three others were described as active and talking. One patient had a GCS of 11 and required assistance for feeding and mobility.

Procedurally:

Most ECTs (60%) were performed by non-specialist medical officers
25% were performed by registrars, and only 9% by specialists
Ultrasound was used in 55% of cases, with pericardial effusion identified in 43% of all patients
Isolated cardiac injuries were the most common finding (36%)

Survival was highest in patients who:

Had a pulse on arrival (29% survived to discharge)
Sustained a stab wound (32% survived to discharge)
Had a single isolated thoracic injury (37% survived)

Should we believe the results?

This is a well-conducted study for its type. As previously mentioned. we are always cautious about retrospective reviews as they always have limitations, especially in documentation quality and case finding. The authors clearly put in a huge effort to identify cases, pulling data from both EC registers and theatre records, and trawling through over 1000 charts. Despite this, the final number (67 ECTs) is lower than the authors estimated caseload, and it’s likely that some cases were missed.

The authors are upfront about limitations, including the lack of a prospectively maintained procedural log, missing documentation, and inconsistent data on functional outcomes. They also acknowledge the heterogeneity of ECT indications and techniques across clinicians, which limits generalisability.

The study design doesn’t allow for statistical analysis of associations, and the relatively small sample size restricts power. But the descriptive nature means we can still draw useful conclusions, especially when comparing to existing literature.

That said, and even with the limitations it’s really interesting and somewhat humbling to contrast the context: this is ECT done in facilities without ICU, blood banks, or even on-site theatre (in one case), by junior staff, often working alone at night. And yet, the survival rate — particularly for stab wounds — is remarkable (24% survival to hospital discharge). It really raises questions about whether the success rate here is a function of the patients, the pathology or the practitioners. I don’t think we have the data here to know, but it’s quite likely to be a combination of all three.

Also I cannot emphasise enough how limited the resources are in the stand alone Emergency Care Centre at Heideveld, where you essentially have an isolated tiny ED, with a short stay ward. There is no on-site support at all and this is often staffed by a singl;e resident doctor, who is responsible for delivering high acuity trauma care.

Should we change practice based on this study?

This is clearly a very different setting and health economy to my practice, but it has made me think again about the indications and in particular the timing of thoracotomy in penetrating trauma. There is a sense here that patients are seen at an earlier phase of pathology than we typically see. Many patients present with a pulse and often by non-EMS. Both of these factors are known to be significant in terms of survival, and that’s my experience too. The patient who is transferred in cardiac arrest to a centre for the thoracotomy rarely does well. The best time to do a thoracotomy is immediately after TCA or just before it! If the patient can get to hospital before they arrest, then so much the better.

Summary

I was delighted to see this paper from a great team in Cape Town. Sittmann et al. have deliveded a pragmatic, well-reported study of emergency centre thoracotomy in two South African district hospitals. It’s certainly made me think once again about ECT and other HALO procedures.

For those of us practising in better-resourced systems, this study is a reminder that HALO interventions are about good training, experience and timing.

Also: Please consider inviting the authors to your next conference, they are fantastic people, great presenters and wonderfully inspiring.