Life after near death: Long-term outcomes of ... - Cedars-Sinai

ORIGINAL ARTICLE 

Life after near death: Long-term outcomes of emergency 

department thoracotomy survivors 

Deborah Keller, MS, MD, Heather Kulp, RN, MSN, Zoe Maher, MD, Thomas A. Santora, MD, 

Amy J. Goldberg, MD, and Mark J. Seamon, MD, Camden, New Jersey 

BACKGROUND: 

METHODS: 

RESULTS: 

CONCLUSION: 

LEVEL OF EVIDENCE: 

KEY WORDS: 

Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of 

long-term outcomes after hospital survival. Our primary study objective was to analyze the long-term social, cognitive, 

functional, and psychological outcomes in EDT survivors. 

Review of our Level I trauma center registry (2000Y2010) revealed that 37 of 448 patients survived hospitalization after 

EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers 

were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death 

Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated 

scoring instruments (Mini-Mental Status Exam, Glasgow Outcome Scores, Timed Get-Up and Go Test, Functional Independence 

Measure Scoring, SF-36 Health Survey, and civilian posttraumatic stress disorder checklist). 

After extended hospitalization (43 T 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 

6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study 

evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), 

daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary 

outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 

81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening. 

Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that 

most of our sampled EDT survivors had no evidence of long-term impairment. It is our hope that these results are considered by 

physicians making life or death decisions regarding the ‘‘futility’’ of EDT in our most severely injured patients. (J Trauma 

Acute Care Surg. 2013;74: 1315Y1320. Copyright * 2013 by Lippincott Williams & Wilkins) 

Prognostic and epidemiologic study, level III. 

Emergency department thoracotomy; long-term outcomes; quality of life. 

Emergency department thoracotomy (EDT) is an established 

procedure that has been used to salvage the most critically 

injured patients. While the indications and predictors of hospital 

survival of the procedure are well defined, 1Y5 EDT remains 

controversial owing to limited survival, perceived risk of occupational 

exposure by health care workers, and the potential 

for salvaging patients with neurologic impairment. 6Y11 

Although proper patient selection and strict adherence 

to universal precautions may diminish some risk associated 

with EDT, the possibility of resuscitating a patient with anoxic 

encephalopathy must be considered. In the review of EDT literature 

from 1974 to 1998 by Rhee et al., 2 23 studies reported gross 

neurologic outcome in EDT survivors before hospital discharge. 

Submitted: July 16, 2012, Revised: December 20, 2012, Accepted: December 20, 2012. 

From the Department of Surgery (D.K.), University Hospital-Case Medical Center, 

Cleveland, Ohio; Alfred I. duPont Children’s Hospital (H.K.), Wilmington, 

Delaware; Division of Trauma and Surgical Critical Care (T.A.S., A.J.G.), Department 

of Surgery (Z.M.), Temple University School of Medicine, Philadelphia, 

Pennsylvania; and Division of Trauma and Surgical Critical Care (M.J.S.), Department 

of Surgery, Cooper University Hospital, Camden, New Jersey. 

This study was presented as a poster at the 70th annual meeting of the American Association 

for the Surgery of Trauma, September 14Y17, 2011, in Chicago, Illinois. 

Address for reprints: Mark J. Seamon, MD, Division of Trauma and Surgical Critical 

Care, Department of Surgery, Cooper University Hospital 3 Cooper Plaza, Suite 

#411, Camden, NJ 08103; email: seamon-mark@CooperHealth.edu. 

DOI: 10.1097/TA.0b013e31828c3db4 

Of the 303 survivors with reported neurologic status, 92.4% 

had ‘‘normal’’ neurologic outcomes before discharge. 3 Other 

reports were less favorable, documenting no neurologically intact 

survivors among blunt trauma victims without signs of life 

in the emergency department (ED) or penetrating trauma patients 

without scene signs of life. 12,13 In a 10-year review of 

290 EDT patients, Millham et al. 13 reported only 4 of their 13 

EDT survivors had normal neurologic function during their 

hospitalization. To our knowledge however, no previous studies 

have evaluated long-term cognitive or functional status in EDT 

survivors after hospital discharge. 

Little is known of the long-term outcomes in those that 

survive their hospitalization after EDT. We hypothesized that 

EDT survivors are able to live healthful, productive lives. Our 

primary study objective was to analyze the long-term cognitive, 

functional, and psychological status in EDT survivors to assess 

their quality of life after hospital discharge. 

PATIENTS AND METHODS 

Temple University Hospital is a state-verified, Level I 

Trauma Center in Philadelphia, Pennsylvania. After institutional 

review board approval, review of the trauma registry 

from January 2000 to December 2010 revealed that 37 of 448 

patients survived their hospitalization after EDT. All patients 

who underwent EDT immediately upon arrival to the ED, 

J Trauma Acute Care Surg 

Volume 74, Number 5 1315 

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Keller et al. 


Volume 74, Number 5 

regardless of age or injury mechanism, were included in this 

analysis. Patients who underwent ‘‘urgent’’ thoracotomy in the 

operating suite were excluded. Indications for EDT included 

loss of signs of life (pupillary response, spontaneous ventilation, 

the presence of a carotid pulse, measurable or palpable 

blood pressure, extremity movement, or any cardiac electrical 

activity) within 15 minutes for patients with penetrating 

trauma or witnessed cardiopulmonary arrest in patients with 

blunt injury. 

Demographics and clinical characteristics from the index 

hospitalization were analyzed in all 37 EDT hospital survivors. 

Measured variables included injury mechanism, anatomic injury, 

the presence of field and ED signs of life, cardiac rhythm, 

method of prehospital transportation, initial ED Glasgow 

Coma Scale (GCS) score, Injury Severity Score (ISS), intensive 

care unit (ICU) length of stay (LOS), number of ventilator 

days, hospital LOS, disposition at hospital discharge, and number 

of readmissions and ED visits after index hospitalization. 

We then attempted to contact each of the 37 hospital 

survivors using inpatient, outpatient, and ED medical records, 

billing reports, State Prison Registries, and online search engines. 

After exhaustive efforts to contact each survivor by telephone 

and mail, 21 patients or caretakers were contacted and 

invited to participate in an outpatient cognitive and functional 

assessment, while 16 hospital survivors were lost to follow-up. 

None of these 16 patients were present in the Social Security 

Death Index. Five of the 21 patients or caregivers contacted 

were unable to participate in outpatient testing (two died after 

hospital discharge [both unrelated to their injuries or EDTVone 

ruptured cerebral aneurysm, one of ‘‘natural’’ causes], one was 

in a persistent comatose state, two participated in telephone 

interviews only). Outpatient evaluations were performed by 

both trauma surgery and physical medicine and rehabilitation 

staff on the final 16 study patients. 

The outpatient assessment began with patient interviews 

by trauma faculty using a study questionnaire focused on patient 

demographics and social data. Each final study patient 

(n = 16) then underwent a comprehensive, multidisciplinary 

assessment consisting of each of the following previously validated 

scoring instruments: Mini-Mental Status Exam (MMSE; 

normal cognition, Q25 points; mild cognitive impairment, 

21Y24 points; moderate impairment, 10Y20 points; severe cognitive 

impairment, e9 points), Glasgow Outcome Scoring (GOS; 

range from full recovery with resumption of normal occupational 

and social activities, score of 1, to dead, score of 5), Timed 

Get-Up and Go Test (TGUG) (impaired mobility 920 seconds), 

Functional Independence Measure (FIM) Scoring range 

from requiring total assistance, score of 1, to complete independence, 

score of 7), civilian posttraumatic stress disorder (PTSD) 

checklist (score 956 indicates moderate or severe PTSD), and 

the Rand Medical Outcomes Study Short Form-36 Health 

Survey (SF-36). To complete the TGUG, the patient is asked to 

stand from the sitting position, walk 10 m around an obstacle, and 

then return to the sitting position after walking 10 m back. The 

civilian PTSD checklist evaluates patients for the 17 Diagnostic 

and Statistical Manual of Mental Disorders, Fourth Edition 

(DSM-IV) symptoms of PTSD using a validated set of questions 

and scoring criteria. Each of the eight SF-36 component scores 

in our study population were compared with US mean scores. 

The primary study end point was the long-term social, functional, 

and psychological outcomes in EDT survivors. Means 

are accompanied by SDs, and percentages of outpatient participants 

are accompanied by ranges (assuming that the 16 patients 

without follow-up did well and assuming that the 16 patients 

without follow-up did poorly). 

RESULTS 

Thirty-seven (8.3%) of the 448 patients who underwent 

EDT survived until hospital discharge (Table 1). These 37 EDT 

survivors were most often young (mean [SD], 32 [9] years), 

males (92%), with severe injuries (mean [SD] ISS, 31 [24]) by 

penetrating mechanisms (gunshot wounds, 65%; stab wounds, 

33%). Prehospital transportation in these survivors varied, 

with 46% of survivors arriving by police, 35% by emergency 

medical service (EMS), and 19% by private vehicle. At admission, 

most survivors were comatose (mean [SD] GCS 

score, 7 [5]) owing to shock. Although both ICU and hospital 

LOS were prolonged (26 [26] days and 43 [41] days, respectively), 

disposition at discharge was varied (home, 62%; rehabilitation, 

32%; skilled nursing facility, 6%), while hospital 

readmissions were common (33%) after discharge. 

Of the 37 EDT hospital survivors, 21 patients or caretakers 

were contacted and invited to participate in our outpatient 

assessment, and 16 patients were lost to follow-up (Fig. 1). 

None of these 16 patients who were lost to follow-up were 

present in the Social Security Death Index. Of the 21 patients 

or caretakers contacted, 2 hospital survivors had died after 

hospital discharge, 1 remained in a persistent comatose state, 

and 2 were available for telephone interview only. 

Each of the remaining 16 long-term EDT survivors completed 

the full outpatient assessment after a mean elapsed time 

from EDT until study participation of 61 (37) months (median, 

59 months). Long-term EDT survivors were often single, divorced, 

or widowed (81%), with children (81%). Daily alcohol 

(50%), illicit drug use (38%), unemployment (75%), 

and incarceration (13%) were common in those who underwent 

the full social, cognitive, functional, and psychological 

outpatient assessment. 

Cognition in long-term EDT survivors was assessed with 

the Folstein MMSE and GOS. The MMSE assesses orientation, 

TABLE 1. 

SF-36 Physical and Mental Components of Health 

Component National Mean Survivors (n = 16) 

Physical function 83 67 (24) 

Role, physical 78 55 (35) 

Bodily pain 70 69 (23) 

General health 70 58 (21) 

Mental health 75 65 (18) 

Role, emotional 83 67 (32) 

Social function 84 63 (23) 

Vitality 57 60 (21) 

Mean (SD) or n (%). 

EDT survivors often scored below national means in the components of the SF-36 

assessment tool. 

1316 * 2013 Lippincott Williams & Wilkins 




Keller et al. 

Figure 1. The final study population. 

word recall, attention and calculation, language abilities, and 

visual-spatial ability on a 30-point scale. While the mean (SD) 

and median MMSE scores were 26 (5) and 28, respectively, 

75% (range, 38Y88%) of our survivors had normal cognition, 

13% (range, 6Y56%) had moderate cognitive impairment, and 

13% (range, 6Y56%) had severe cognitive impairment (Fig. 2A). 

Cognition and capacity to return to normal occupational and 

activities were evaluated with the GOS. Similar to the MMSE 

distribution, GOS (Fig. 2B) demonstrated that 75% (range, 

38Y88%) of our survivors had good recovery (GOS, 1), 13% 

(range, 6Y56%) had moderate disability (GOS, 2), and only 

13% (range, 6Y56%) had severe disability (GOS, 3). 

The functional outcomes of our EDT survivors were 

analyzed with the FIM score and TGUG. The mean (SD) and 

median FIM score of our survivors was 6.3 (0.1) and 7, respectively, 

with a range from 6.2 to 6.4 in each subactivity 

mean FIM score (Fig. 3A). The TGUG, evaluating mobility 

and independence, determined that 81% (range, 41Y91%) of 

study participants were freely mobile, 6% (range, 3Y53%) 

had mild or moderately impaired mobility, and 13% (range, 

6Y56%) were severely impaired and required wheelchairs 

(Fig. 3B). 

Patients with any type of long-term follow-up (full outpatient 

assessment, telephone interview with patient, caretaker, 

or family member) were then compared with respect to 

degree of long-term cognitive or functional impairment after 

EDT (Table 2). While patients without cognitive or functional 

impairment (n = 11) were younger (28 [6] years vs. 39 [11] 

years, p = 0.007) and less often transported by police (27% vs. 

80%, p = 0.030) than those with any evidence of impairment 

(n = 10), there were no differences in injury mechanism, anatomic 

injury location, injury severity, signs of life, cardiac 

rhythm, or GCS score (all p 9 0.05) between these groups. 

Psychological outcome and quality of life were also 

analyzed. EDT survivors were screened for PTSD using the 

PTSD Civilian ChecklistVa previously validated screening 

tool that demonstrated 25% (range, 13Y63%) of the present 

study participants met the criteria for PTSD. The Rand Medical 

Outcomes Study Short Form-36 Health Survey (SF-36) 

was used to examine the long-term quality of life in our 

EDT survivors as compared with validated national mean 

scores (United States, 1998) for each of the eight SF-36 components 

(Table 1). 

In summary, of the 16 patients who underwent the comprehensive, 

multidisciplinary outpatient assessment after a 

median of 59 months following EDT, 75% had normal cognition 

and returned to normal activities, 81% were freely 

mobile and functional, and 75% had no evidence of PTSD 

upon outpatient screening. 

DISCUSSION 

We have determined that of the 8.3% of patients who 

survived hospitalization after EDT, the majority of our sampled 

EDT survivors had no evidence of cognitive, functional, 

or psychological long-term impairment. To our knowledge, 

this study is the first to evaluate the long-term status of EDT 

survivors after hospital discharge. While some physicians 

may avoid the potential life-saving procedure for fear of salvaging 

a severely impaired patient, careful analysis however 

of previous reports describing either critically ill ICU patients, 

Figure 2. Cognition in long-term EDT survivors was assessed by MMSE (A) and GOS (B). 

* 2013 Lippincott Williams & Wilkins 1317 


Keller et al. 



Figure 3. Functional outcomes in long-term EDT survivors were evaluated with FIM testing (A) and TGUG (B). 

traumatic brain injury (TBI) patients, or critically ill general 

trauma patients yields very similar results. 14Y25 

While no previous studies have evaluated the long-term 

outcomes of patients after EDT, long-term outcomes and 

quality of life after critical illness with a prolonged ICU course 

have been described. 14,15 Oeyen et al. 14 performed a systematic 

review of the literature regarding quality of life after intensive 

care. In the meta-analysis of 53 studies, critically ill patients 

uniformly had a lower quality of life compared with an age- and 

sex-matched population 1 year after intensive care. Despite 

a primarily young and healthy population, severe trauma patients 

experienced significant reductions in both physical and 

TABLE 2. Presenting Clinical Variables Were Compared With 

Respect to Long-Term Cognitive and Functional Outcomes 

No Impairment 

(n = 11) 

Any Impairment 

(n = 10) p 

Age, mean (SD), y 28 (6)* 39 (11) 0.007 

Mechanism 

Gunshot wound 7 (64%) 6 (60%) 1.000 

Stab wound 4 (36%) 4 (40%) 1.000 

Primary injury location 

Cardiac 4 (36%) 5 (50%) 0.670 

Thoracic 4 (36%) 3 (30%) 1.000 

Abdominal 3 (27%) 2 (20%) 1.000 

ISS, mean (SD) 29 (19) 25 (20) 0.698 

Field SOL 11 (100%) 9 (90%) 0.476 

ED SOL 9 (82%) 9 (90%) 1.000 

Cardiac rhythm 

Asystole 2 (18%) 1 (10%) 1.000 

Agonal/PEA 2 (18%) 2 (20%) 1.000 

Sinus 7 (64%) 7 (70%) 1.000 

GCS score, mean (SD) 9 (6) 8 (6) 0.678 

Prehospital transport 

Police 3 (27%) 8 (80%) 0.030 

Private vehicle 3 (27%) 0 0.214 

EMS 5 (46%) 2 (20%) 0.362 

*Mean (SD). 

SOL, signs of life; PEA, pulseless electrical activity. 

Twenty-one patients or caretakers were contacted, 2 hospital survivors had died after 

hospital discharge, 1 remained in a persistent comatose state, 2 were available for telephone 

interview only, and 16 long-term EDT survivors completed the full outpatient 

assessment. 

psychosocial quality-of-life measures and less often returned to 

work. Timmers et al. 15 performed a prospective observational 

cohort study of surviving surgical ICU patients during a 5-year 

period to quantify their quality of life. Trauma patients more 

often (odds ratio, 2.5Y3.5) had problems with mobility, selfcare, 

usual activities, and cognition than other surgical patients. 

After a mean ICU LOS of 26 days, our findings in EDT 

patients are concordant with these studies of general surgical 

ICU patients. 

Long-term outcome after TBI has been well studied. 16Y18 

While our EDT survivors were primarily victims of penetrating 

trauma without TBI, a review of reports describing 

long-term outcome after TBI does illustrate the negative impact 

injury has on another subset of the population. Livingston 

et al. 17,18 measured functional status before hospital 

discharge and after a 2 year follow-up using both GOS and 

FIM tests. With lower FIM scores and greater unemployment 

rate, Livingston et al. 17,18 concluded that TBI patients 

requiringprolongedICUcaremayhave‘‘afateworsethan 

death.’’ Importantly, age was an important determining factor 

in long-term outcomes in each of these studies. Increasing 

age was associated with long-term impairment after EDT in 

the present report also. Importantly, the EDT population consists 

primarily of young males. With a mean age of 32 years 

in our EDT survivors, EDT patients are often younger, are 

stronger, and have a greater opportunity for recovery than their 

elder, critically injured counterparts. 

The long-term outcomes after general trauma have also 

demonstrated persistent cognitive, functional, and psychological 

issues affecting the quality of life in survivors. 19Y25 

Holbrook et al. 20 reported similar results to the present study 

in 6-month follow-up in general trauma patients. The authors 

determined that hospital LOS greater than 7 days, ICU LOS 

greater than 4 days, and ISS of greater than 10 were factors 

that negatively impacted outcomes. 23 Despite the presence 

of these characteristics in each of our EDT survivors, most of 

the sampled survivors had no evidence of long-term cognitive 

or functional impairment. 

While no difference in ISS was detected between contacted 

patients with no long-term impairment or any impairment, 

cognitively or functionally impaired patients were more 

likely to have been transported by police (80%) compared with 

unimpaired EDT survivors (27%). This finding merits attention 

and two possible explanations. Cardiopulmonary resuscitation 





Keller et al. 

is seldom performed by police when transporting critically 

injured patients in PhiladelphiaVa phenomena that may encourage 

anoxic encephalopathy in this population. Importantly, 

patients with any degree of long-term cognitive or functional 

impairment were compared. Second, we have previously 

reported that hospital survival after EDTis adversely affected by 

prehospital EMS resuscitation and procedures. 26 Another 

plausible explanation for the association between police transport 

and impairment is that although hospital survival is improved 

after minimal prehospital intervention in this population, 

some hospital EDT survivors may experience long-term cognitive 

and functional impairment. 

The quality-of-life and psychological impact of major 

trauma on survivors also merit attention. Soberg et al. 23 used 

the SF-36 to analyze long-term outcomes 2 years after severe, 

polysystem injury. Similar to our findings, severely injured 

patients fared worse than the general population in SF-36 measures. 

With 25% (range, 13Y63%) of our EDT survivors screening 

positive for PTSD, better recognition and long-term therapy 

may improve outcomes. Although infrequently reported, the 

prevalence of PTSD in our long-term EDT survivors is consistent 

with other series describing PTSD after major trauma. 19,20,27 

Holbrook et al. 19 reported outcomes 18 months after injury 

and discovered high rates of depression and PTSD (35%)V 

factors that were independently associated with poor functional 

outcomes in injury survivors. 

We recognize our study limitations. This study represents 

the analysis of long-term outcomes in EDT survivors 

primarily after penetrating injury (36 of 37 survivors) from a 

single institution, and results may not be applicable to other 

injury mechanisms or other trauma systems. Study participation 

was not uniform as 16 of 37 EDT hospital survivors were 

completely lost to follow-up. Lastly, our study lacks a comparison 

or control group. While a ‘‘non-EDT’’ control group 

with similar critical injuries is not possible owing to practical 

and ethical considerations, we have compared our findings to 

those of previous reports describing long-term outcomes in 

general trauma patients have discovered similar results. 

Despite the common belief that EDT survivors often live 

with severe neurologic or functional impairment, we have 

found that most of our sampled EDT survivors had no evidence 

of long-term impairment. It is our hope that these results 

are considered by physicians making life or death decisions 

regarding the ‘‘futility’’ of EDT in our most severely injured 

patients. However, the potential for severe long-term impairment 

after EDT should not be overlooked. Similar to other 

critically injured trauma populations, survivors of EDT also 

face significant challenges after hospital discharge. While additional 

study is required, more rigorous outpatient follow-up 

may further improve long-term outcomes in EDT survivors. 

AUTHORSHIP 

D.K. contributed in the literature search, study design, data collection, data 

analysis, data interpretation, drafting of the manuscript, critical revision, 

and final article approval. H.K.P. contributed in the literature search, data 

collection, and final article approval. T.A.S. contributed in the data collection 

and final article approval. A.J.G. contributed in the data collection, 

and final article approval. M.J.S contributed in the literature search, study 

design, data collection, data analysis, data interpretation, drafting of the 

manuscript, critical revision, and final article approval. 

ACKNOWLEDGMENT 

We acknowledge Drs. Niteesh Bharara, Gilbert Siu, and Ernesto Cruz 

from the Temple University School of Medicine, Department of Physical 

Medicine and Rehabilitation, for their assistance with this project. 

DISCLOSURE 

The authors declare no conflicts of interest. 

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