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Professional rescue: mini open-heart surgeries

(Bild: APA/GEORG HOCHMUTH)

In absolute emergencies following stabbing or firearm attacks, the Vienna Professional Rescue Service intends to increasingly perform open-heart surgery on site in future. The procedure used for this - known as "clamshell thoracotomy" - is still relatively new in this country. However, this procedure often gives the patient a far greater chance of survival.

In a clamshell thoracotomy, the chest of patients with circulatory arrest is opened "to make a makeshift repair of life-threatening injuries", as head physician Mario Krammel outlined during a background discussion.

Clamshell thoracotomy

• Specifically, the procedure involves a horizontal incision between the ribs. The second step involves the makeshift treatment of the internal injuries - including internal cardiac massage and sutures.
• This method, which is based on the "opening of a clam shell", is still relatively new in Austria, but has become popular in rescue services in London and Berlin, among other places.
• This type of treatment is only ever carried out by experienced emergency doctors. Staff from the ambulance service assist in the process.
• The main indications for the use of such treatment are life-threatening gunshot or stab wounds to the heart, lungs or other major vessels in conjunction with cardiac arrest. However, this method can also be used for patients with "impalement injuries".

"We saw this ten years ago in Berlin and thought about how we could bring this training to Vienna," said emergency doctor Krammel, one of the originators of the idea at the professional rescue service. Now the time has come and "clamshell thoracotomies" can be performed throughout the capital if required.

100 emergency doctors and 80 emergency paramedics have been trained so far, with more to follow. This makes Berufsrettung a pioneer throughout Austria. "We are venturing into a field that was not previously common in pre-hospital care in this form," added a spokesperson.

What we are doing here is really an absolute emergency measure in the context of resuscitation when the heart has stopped beating.

Chefarzt Mario Krammel

Often seconds make the difference between life and death
However, Krammel makes a conscious effort to differentiate the procedure: "We are not surgeons." The widespread introduction of the procedure is not intended to stir up competitive thinking. "What we do here is really an absolute emergency measure in the context of resuscitation when the heart has stopped beating." After all, Krammel explained, seconds are often decisive in determining whether a patient lives or dies.

"Cardiac massage and a defibrillator are useless"
Past experience in the emergency services has shown that acute blood loss, a collapsed lung, a lack of oxygen or an accumulation of blood in the pericardium can lead to a - often ultimately fatal - circulatory arrest.

"And that's where cardiac massage and defibrillators are useless. We can't help our patients in any other way - except with this emergency measure, so that we can get them to hospital as quickly as possible," says Krammel. "Otherwise they would have no chance of survival."

(Bild: APA/GEORG HOCHMUTH)

(Bild: APA/GEORG HOCHMUTH)

Survival rate at 35 percent 
In this context, he referred to studies on the survival rate after a "clamshell thoracotomy" as a result of circulatory arrest due to cardiac injury. According to these studies, 35 percent of those treated remained alive as a result of such treatment. In 2022, after years of deliberation, a training project for clamshell thoracotomy was finally launched.

Procedure already used several times since 2023
In January 2023, the professional rescue team had to resort to the new measure for the first time. At the time, a 60-year-old man had loudly knocked on his neighbor's door in Kienmayergasse in Penzing with a firearm. After an ensuing exchange of fire with the police, the man was shot by Cobra officers and ultimately died despite receiving emergency treatment. A total of three operations involving clamshell thoracotomy were counted in 2023. Five people were treated in 2024. Two of them survived their injuries, most recently a young mother of two in Vienna-Penzing in August 2024 after suffering life-threatening stab wounds. "And that's exactly why we do this."