Finger Thoracostomy Kits: A New Tool in the EMS Toolkit

Lieutenant Andy Torres of the Miramar (Florida) Fire-Rescue Department, a 15-year SWAT medic, had contemplated approaches to traumatic cardiac arrest and concluded that there were techniques that weren’t being utilized that could really help patients.

“The second leading cause of death secondary to a traumatic injury is that unrecognized tension physiology that can exist within the chest,” he says, adding needle decompression has been a traditional response.

“It’s debatable on how effective that is at actually relieving that true tension physiology that exists, whether it's a pneumothorax, hemothorax, or a combination of the two,” he says. “When we have a patient in traumatic cardiac arrest and the mechanism is telling us that tension physiology may exist, that essentially was the driving force behind doing finger thoracostomy.”

Traumatic Cardiac Arrest

Miramar Fire-Rescue serves a population of 140,328 (with commerce visitors increasing those numbers) with a staff of 150 in 31.08 square miles. The department responds to 13,000 calls per year, with 84 percent being EMS.

Torres notes traumatic cardiac arrest doesn't typically end well for the patient.

“But while they are in the back of my truck, I want to give them every opportunity at life. I'm sure their family members and friends would appreciate that,” he says.

Tony Chin concurs.

“If we can just save a couple of these trauma codes a year, that's one more person who goes home to their family,” he says. “If we can good at what we do, hone in on doing this procedure and pull them out of cardiac arrest or even in the pre-arrest situation preventing them from going into cardiac arrest, the benefits outweigh the challenges.”

Chin is Coconut Creek Fire Rescue’s assistant fire chief of administration, which serves 60,000 people in a 12-square mile radius north of Miramar in Broward County, Florida.

The department runs about 8,000 calls yearly through three fire stations, each housing a suppression and a rescue unit and the main station housing the shift battalion. There are three ALS transport units and three ALS non-transport suppression units.

“We were doing finger thoracostomy with our tactical medicine group in reference to gunshot wounds to the chest and in reference to the pneumothorax that we can actually fix in the field relatively quickly,” says Chin.

During training, Chin was telling paramedics to breathe through a 14-gauge needle or 12-gauge needle.

“They’re trying to push through, and they couldn't get enough air in, nor could they get enough air out,” he says. “We did understand the pathophysiology. We evaluated all situations and found that a one-inch incision was far superior to normal needle decompression.

A New Program for Finger Thoracostomy

The program was implemented with the encouragement of the department’s medical director, Dr. Craig Kushnir.

Every unit is equipped with one kit, with spare kits at the station. The kit also is carried by the department’s three tactical medics and Chin, the tactical medic commander. 

“The driving force was to give our paramedics one more tool in the toolbox to be able to save a life, whether it's going to be a pneumothorax, a pneumothorax or general prearrest sign and symptoms of a pneumothorax either secondary to trauma or obviously medical pneumothorax called a bleb,” Chin says.

Chin notes after EMS picks up the patient, the patient is evaluated, and a confirmation is made that they’re either in a pre-arrest or a pulseless electrical activity arrest situation secondary to either blunt trauma or penetrating trauma to the chest.

“The finger thoracostomy kit gives you all the landmarks and walks you through the procedure,” Chin says. “Normally, the patient would probably get bilateral chest decompressions with 12- or 14-gauge three-inch needles. That is not enough surface area to release a large pneumothorax that's tension-related. We like to get a larger hole.”

“Right along the nipple line – which probably runs in the area of a person’s third and fourth intercostal midaxillary – we make a small incision with a scalpel. Once we cut away the skin, we look at the pleural space. Then we use a set of large hemostats and puncture that pleural space with the hemostat, put our finger in there, and do a finger sweep to get all the air out.”

It entails a one to 1.5-inch incision versus a 12- or 14-gauge needle orifice, Chin says, adding “You’re talking about an exponentially large area to relieve a pneumothorax as it pertains to tension pneumothorax. 

“After we make that hole and relieve pressure, we cover the hole with a North American Rescue chest seal. It has venting avenues that will be able to burp the pneumothorax continuously and not have to utilize the needle where you have a one-way valve or a stopcock to open it up and close it several times to relieve pressure.”

When air starts to go in, it collapses and prevents any air from going in when intercostal pressure changes, Chin says, adding “It’s a one-way valve that lets air out and it doesn't let air in.”

Challenges in Implementation

Torres notes getting all stakeholders in a municipality to agree to finance a new approach may be challenging for some.

The equipment entailed nominal expenses. Memorial Regional Hospital in Hollywood – which housed one of the local trauma centers – loaned the department a mannequin on which the entire department was trained in finger thoracostomy for six weeks.

Coconut Creek Fire Rescue partnered with Miramar Fire-Rescue and Memorial Regional Hospital, which also provided Coconut Creek with a mannequin for the training.  

The mannequin simulates breathing and produces a rush of air when popped. There are extra costs entailed for replacement skins and for the pleural space, Chin says. He estimates the training to cost $2,000 a session, with three weeks of training for 80 people.

The department had budgeted for 40 kits and training costs for fiscal year 2023.

Putting the Kits to Use

Since instituting the program, Miramar Fire-Rescue has implemented finger thoracostomy twice.

“The opportunity for the first one in the field was mine,” says Torres. “Unfortunately, the outcome did not change for that patient; they died as a result of their injuries. In the second case where finger thoracostomy was done on that patient, I believe that person did survive.”

As of early October, Coconut Creek Fire Rescue has not put the kits to use yet.  

“It's a foreign concept of taking a scalpel and opening an inch to an inch and a half incision into a chest,” says Torres. “That's not typical for paramedics. Advice I was given by one of the trauma surgeons during my training process for the procedure is that you just need to have about 15 seconds of bravery to get past that concept of making a hole in someone's chest and you potentially can increase their survivability exponentially.”

Chin says the kits and procedure can significantly improve the mortality rate of the patient. The rate depends on the cause of cardiac arrest, but averages between 10 and 20 percent survival, with mortality rates ranging from 80 to 90 percent, he says.

“Only a handful of departments have done it so far,” says Chin. “I think it's going to be something relatively large in reference to looking at Tactical Combat Casualty Care. All tactical-type classes offer this.”

Evaluating Their Impact

Chin hopes that for a patient population in such dire need, these kits can be beneficial.

“I hope it impacts the patient in a positive sense,” Chin says. “We also understand that these are dire patients right off the get-go of a post-cardiac arrest or a pre-cardiac arrest secondary to traumas and survivability is already limited.”

Chin says the success of implementing a new program is to listen to others in the department, from the chief down to those with no rank. He had listened to three tactical medical people who indicated they probably could have saved a life if the kits were available on certain calls.

It’s also important to engage in ongoing training as well as have a progressive medical director on staff, Chin adds.

“There are a lot of doctors out there that are set in their in their ways,” says Chin. “They do medical direction for the wrong reasons – whether it’s financial gain, political gain, or whatever. The medical directors of today’s fire rescue or EMS organizations need to be progressive, current, going to conferences and reading periodicals to find out what is currently going on in the arena.”