# Bilateral tension pneumothorax? Oh my!



## apagea99 (Dec 5, 2008)

On Monday night, my class went over chest injuries with an emphasis on pneumothoraces (open, closed, spontaneous, tension, hemopneumothorax), s/s, and what interventions can be offered by an EMT-B (or IV here in TN). 

On Tuesday, my study partner and I did some online reading and came across an article on bilateral tension pneumothorax. Our reaction was mostly along the lines of $@%$*%&$^!!!!!!!! This is something that wasn't mentioned in class and I'm guessing it may be very rare (?). So my questions are these: Has anyone seen cases of this while working as a Basic? Were the s/s evident from the start or still developing? Did you recognize them right away? Did you have ALS with you or did you have to activate them en route? How did the pt fare?

After doing some further reading, it seems that all an EMT-B can really do is recognize the s/s, activate ALS asap, and provide rapid transport. Please feel free to kick me if I'm off base.......

BTW - I realize that the life saving interventions needed here are ALS skills. I just wanted to know if any Basics had come across them and how they dealt with them on a Basic level. That being said, I'd like to know what the medics have to say too


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## FF894 (Dec 5, 2008)

Like you said at the B level you just have to transport quick and hope to meet ALS on the way.  The assessment to that point will be key to allow ALS to make a decision so the having good assessment skills at any level is key.  At the ALS level, where I am, if the case is a trauma and the patient is rapidly headed towards arrest then it doesn't hurt to needle both sides.


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## KEVD18 (Dec 5, 2008)

if you have a pt with bilateral pneumothoraces at the bls level, you'd better hope there are medics available toot sweet.


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## traumateam1 (Dec 5, 2008)

Like I've said many many times, we don't have any ALS here, so IV, O2 and rapid transport. Activate a trauma alert at the hosp and go go go. Oh yeah and hope you have enough time to get to the hospital before he stops breathing, and then his heart stops.

Never seen a bilat. tension pneumothorax tho.


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## Ridryder911 (Dec 5, 2008)

There is a lot of things that Basics are not taught. Things such as there are not such things as a unilateral pelvic fracture or mandibular fracture. 

I have treated a few bi-lateral tension pneumo's and prefer if possible care not to see anymore. 

R/r 911


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## tydek07 (Dec 5, 2008)

Hi,

You are 100% correct that you need ALS asap. One of my main concerns (as Ryder pointed out) is that some stuff like this is not gone over like it should be in EMT courses. They may talk about it, as its in the book, but usually do not go very far into it. Its awsome that you are doing your own research and going further into stuff like this! 

The biggest thing an EMT can do is recognize the problem and/or try to prevent it (ie. using an occlusive dressing(s)). Also get ALS en route right away for an intercept. This is a life or death situation, so being able to recognize the problem is key.

Have I seen a bi-lateral tension pneumo before? Nope, and hope that my luck continues for a long time 

Again, its nice seeing that you are going further into stuff on your own time.  It shows that you really want to learn and be the best EMT you can be.

Take Care,


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## boingo (Dec 6, 2008)

If the tension is caused by a penetrating chest injury you could insert your finger and decompress it.  It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure.  I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices.  Your patient will die quickly, or you will think outside the box.


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## Ridryder911 (Dec 6, 2008)

boingo said:


> If the tension is caused by a penetrating chest injury you could insert your finger and decompress it.  It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure.  I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices.  Your patient will die quickly, or you will think outside the box.



Gasp!... Want to keep out of jail and the least have some money for groceries? *Then NEVER EVER PERFORM THAT PROCEDURE!*

Part of the problem of Internet. The reason this is not in any text or taught, is simply its *WRONG and could perceived as GROSS NEGLIGENCE and POSSIBLY MANSLAUGHTER!* 

Chest decompression is an advanced skill. Period! Now, the proper procedure for *Advanced Personnel* is chest decompression with a large bore *needle* with an attached flutter valve (or similarities). The * only * mention of incising and placing a *sterile* finger inside the pleura is when placing a chest tube.. in which there are very few EMS services allowed to perform the procedure. 

R/r 911


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## boingo (Dec 6, 2008)

LOL  Wrong because its not in a book, or wrong because it doesn't work?  I certainly don't suggest going off the reservation, thats why I said Medical control, but as a BLS provider, you have no options.  Opening the pre existing hole CAN relieve the pressure, to suggest otherwise is false.  I'm not telling anyone to go out there and do it, however it IS an option and it DOES work.


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## Ridryder911 (Dec 6, 2008)

boingo said:


> LOL  Wrong because its not in a book, or wrong because it doesn't work?  I certainly don't suggest going off the reservation, thats why I said Medical control, but as a BLS provider, you have no options.  Opening the pre existing hole CAN relieve the pressure, to suggest otherwise is false.  I'm not telling anyone to go out there and do it, however it IS an option and it DOES work.



Why perform such a procedure if there is more appropriate and better way to treat a patient. Have you ever wondered why it is NOT taught or placed in curriculum's?
As a BLS provider you do have options. The way you are taught and allowed to perform. Anything else is performing (unapproved medical procedures) and practicing medicine without a license = litigation and jail time. 

Remember the parts that has be to proven for gross negligence? ...hint: actions as other with the same license/certification would had have acted or performed the same as the actions you performed. As well; followed approved procedure(s) (based upon national and local curriculum/standards). 

As well, I doubt there is a physician (if they like to keep their license and low malpractice) they will give an order of such. I would hope they would not to tell you to take actions above your level or at least an approved medical procedure. 

Place a 3 sided occlusive dressing as taught and rendezvous with ALS, or rapid transport. 

It's great to make recommendation(s) on EMS forums, but let's give sound medical advice that is approved and at least is legitimate by an authority body. 

I would not even suggest discussing with your Medical Director, as they might percieve you as a "cowboy" and dangerous type. 

R/r 911


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## boingo (Dec 6, 2008)

But as an EMT B there is no way to treat this patient.  The patient is in extremis and is going to die in short order.  Tension pneumothorax is a life threatening emergency, and since an  EMT B doesn't have the equipment or education to decompress a chest, the simple insertion of a finger, or opening the wound with traction can allow built up air to escape.  I don't advocate anyone going out there and doing it, don't advocate breaking protocal, just pointing out that there are techniques other than a large bore needle that can help alleviate tension pneumothorax.  I appologize to anyone who may have been given the impression that it was ok for them to try it tonight.


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## Ridryder911 (Dec 6, 2008)

Hence the need for Paramedic Life support on all EMS units. 

R/r 911


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## traumateam1 (Dec 6, 2008)

Haha shoulda read rest of the posts before typing that long reply. -sigh- oh well.


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## Sasha (Dec 7, 2008)

boingo said:


> But as an EMT B there is no way to treat this patient.  The patient is in extremis and is going to die in short order.  Tension pneumothorax is a life threatening emergency, and since an  EMT B doesn't have the equipment or education to decompress a chest, the simple insertion of a finger, or opening the wound with traction can allow built up air to escape.  I don't advocate anyone going out there and doing it, don't advocate breaking protocal, just pointing out that there are techniques other than a large bore needle that can help alleviate tension pneumothorax.  I appologize to anyone who may have been given the impression that it was ok for them to try it tonight.



How would opening a sucking chest wound even more provide pressure relief?


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## boingo (Dec 7, 2008)

Because if the air is able to enter but not exit the chest the pressure (tension) will continue to rise leading to rapid cardiovascular collapse.  Opening the defect to digitally decompress the chest would allow the air under pressure to escape.  After the pressure has been relieve, an occlusive dressing would be applied to prevent any air from entering the chest via the defect.


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## BossyCow (Dec 7, 2008)

boingo said:


> Because if the air is able to enter but not exit the chest the pressure (tension) will continue to rise leading to rapid cardiovascular collapse.  Opening the defect to digitally decompress the chest would allow the air under pressure to escape.  After the pressure has been relieve, an occlusive dressing would be applied to prevent any air from entering the chest via the defect.



And while you are mucking around in there with your finger... the air is prevented from going in how?


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## boingo (Dec 7, 2008)

BossyCow said:


> And while you are mucking around in there with your finger... the air is prevented from going in how?




Because of the law of physics.  The air inside the chest is under much higher pressure than outside, therefore when the chest is opened to atmospheric pressure, the net movement of air is OUT of the chest, not in.  After the pressure is released an occlusive dressing would prevent the movement of air back into the chest.


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## Sasha (Dec 7, 2008)

boingo said:


> Because of the law of physics.  The air inside the chest is under much higher pressure than outside, therefore when the chest is opened to atmospheric pressure, the net movement of air is OUT of the chest, not in.  After the pressure is released an occlusive dressing would prevent the movement of air back into the chest.



In THEORY. But if that were the case, wouldn't the air move out of the smaller hole to begin with? Why would you need to make it bigger? Because when someone tries to inspire, they pull air INTO the chest, and you have created a bigger hole for the air to go INTO.

 I would not recommend that, or suggesting that to ANYONE because you'll wind up in court with a wrongful death lawsuit.


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## boingo (Dec 7, 2008)

Some wounds act as a one way valve, where air is pulled in, but cannot escape.  This isn't theory, its fact.  I am not suggesting anyone deviate from protocol or attempt this because I posted it.  The fact is, digital decompression works, I've done it, it is taught by the trauma surgeons here during ATLS and it other con-ed.  Anyone who has ever put in a chest tube can attest to the fact that air under pressure will rapidly escape once the pleura has been penetrated.


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## BLSBoy (Dec 7, 2008)

boingo said:


> If the tension is caused by a penetrating chest injury you could insert your finger and decompress it.  It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure.  I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices.  Your patient will die quickly, or you will think outside the box.


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## rmellish (Dec 7, 2008)

boingo said:


> Some wounds act as a one way valve, where air is pulled in, but cannot escape.  This isn't theory, its fact.  I am not suggesting anyone deviate from protocol or attempt this because I posted it.  The fact is, digital decompression works, I've done it, it is taught by the trauma surgeons here during ATLS and it other con-ed.  Anyone who has ever put in a chest tube can attest to the fact that air under pressure will rapidly escape once the pleura has been penetrated.



Physics aside, this is a horrible idea.


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## traumateam1 (Dec 7, 2008)

BLSBoy.... hahahaha!!!
That was halarious, thanks for the laugh after a long day.


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## BLSBoy (Dec 7, 2008)

Glad I could help. Did ya get my last PM?


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## traumateam1 (Dec 7, 2008)

BLSBoy said:


> Glad I could help. Did ya get my last PM?



Yes, thank you!


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## Ridryder911 (Dec 7, 2008)

Here's the deal. I have audited ATLS (only physicians are allowed to obtain a certificate). I don't recall of ever inserting a finger to relieve a tension pneumo. It is taught to insert a finger into the site where a chest tube is to be place to locate the pleura lining. Remember more than physics, anatomy of a tension pneumo. Air is in the pleural space not the lung so pressure is between the spaces is causing the tension. 

As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section). Remember, the posts was about bi-lateral tension as well. 

I will gladly testify against any EMT as an expert witness for those that performed such a procedure for free. It is NOT an approved approach nor should ever be performed in the field setting. 

R/r 911


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## traumateam1 (Dec 7, 2008)

Ridryder911 said:


> Here's the deal. *I have audited ATLS (only physicians are allowed to obtain a certificate).* I don't recall of ever inserting a finger to relieve a tension pneumo. It is taught to insert a finger into the site where a chest tube is to be place to locate the pleura lining. Remember more than physics, anatomy of a tension pneumo. Air is in the pleural space not the lung so pressure is between the spaces is causing the tension.
> 
> As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section). Remember, the posts was about bi-lateral tension as well.
> 
> ...



Advanced Trauma Life Support right Rid? Only physicians are allowed to get a cert. in the US?


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## Ridryder911 (Dec 8, 2008)

Yeah, one can be accepted to "audit" a course but must be a physician to be certified. 

R/r 911


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## boingo (Dec 8, 2008)

Please then, lock the thread in case someone gets the idea that our discussing digital decompression will lead to someone breaching protocol.  Do a little research before you discount the procedure.   

BLS Boy:  You haven't even worked ALS, you're two months out of a Florida medic mill, so you FAIL.  I will debate Rid all day, for at least he speaks from his own, lengthy experience.  I won't necessarily agree with him, but he's earned the right.  When you have several more years of education and experience please feel free to add to the conversation, Padawan. :blush:


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## apagea99 (Dec 8, 2008)

Some part of me should have known this would devolve into some sort of argument that has nothing to do with the actual questions I asked LOL

So....I'll re-post them and see if they get answered.



> So my questions are these:
> Has anyone seen cases of this while working as a Basic?
> Were the s/s evident from the start or still developing?
> Did you recognize them right away?
> ...


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## Sasha (Dec 8, 2008)

boingo said:


> Please then, lock the thread in case someone gets the idea that our discussing digital decompression will lead to someone breaching protocol.  Do a little research before you discount the procedure.
> 
> BLS Boy:  You haven't even worked ALS, you're two months out of a Florida medic mill, so you FAIL.  I will debate Rid all day, for at least he speaks from his own, lengthy experience.  I won't necessarily agree with him, but he's earned the right.  When you have several more years of education and experience please feel free to add to the conversation, Padawan. :blush:



Considering this is posted in the BLS section, he didn't FAIL. He may or may not be from a medic mill, but at least he's not recommending some stupid, dangerous, and incorrect procedure. Don't discount someone becasue they have less experience than you, because lack of experience doesn't make you completely dumb, and experience, as you have shown here, doesn't make you automatically smart, and doesn't mean you know what you're talking about.


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## boingo (Dec 8, 2008)

Yes, posting FAIL with stupid pictures adds to an academic discussion, sorry, I missed that part of school.  I merely offered another option for decompressing a tension ptx caused by a penetrating injury, although I never condoned ANYONE perfoming outside their scope.  I thought the professionals on this site enjoyed discussing these topics, even when the opinions differ, I guess I was wrong.  As for stupid, dangerous, and incorrect procedures you clearly know nothing about it.  If BLSBoy has an actual opinion other than FAIL, with some science of education behind it, I'm all ears.  I don't have a problem listening to those with less experience, but his post offers no arguement, just juvenile humor.  I'm done with this topic.


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## traumateam1 (Dec 8, 2008)

Ridryder911 said:


> Yeah, one can be accepted to "audit" a course but must be a physician to be certified.
> 
> R/r 911



Oh, you just need to me advanced life support here in BC to take ATLS, and be a first responder/paramedic to take BTLS. Interesting.


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## rescuepoppy (Dec 8, 2008)

*Discussing Topics*



boingo said:


> Yes, posting FAIL with stupid pictures adds to an academic discussion, sorry, I missed that part of school.  I merely offered another option for decompressing a tension ptx caused by a penetrating injury, although I never condoned ANYONE perfoming outside their scope.  I thought the professionals on this site enjoyed discussing these topics, even when the opinions differ, I guess I was wrong.  As for stupid, dangerous, and incorrect procedures you clearly know nothing about it.  If BLSBoy has an actual opinion other than FAIL, with some science of education behind it, I'm all ears.  I don't have a problem listening to those with less experience, but his post offers no arguement, just juvenile humor.  I'm done with this topic.



  Boingo you will find many people on this forum who will discuss topics with you. But if you are wanting a discussion you have to post something that is reasonable. Also be able to take advice and even cricism. When you make post like the one you did all you have done is open the door for someone to take shots at you.


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## BossyCow (Dec 8, 2008)

Right, we're a lot less likely to jump all over someone who posts.. "Can this be done" instead of "Do this" One invites discussion, the other invites a whole other assortment of responses.


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## ffemt8978 (Dec 8, 2008)

I'm not going to lock this thread yet, because there is potential for a great discussion.  However, I will be paying particular attention to this thread in the future.

Consider this your only warning...please keep this discussion civil and on topic (which it has done for the most part so far).  If I have to lock this thread for any reason, rest assured that the person(s) responsible will get a short vacation from this forum.


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## jrm818 (Dec 8, 2008)

Sasha said:


> [...]some stupid, dangerous, and incorrect procedure [...]



I'm not going to comment on the advisability of performing surgical procedures as an EMT in extreme situations...that's for an individual to decide.

However, you sound a bit like you're attacking without doing much research.  Try typing "digital decompression pneumothorax" into google scholar.  Read the first paper (as an example..plenty of others. This one is a contemporary review with clinical advice, so it's particularly relevant): "Pleural decompression and drainage during trauma reception and resuscitation," Fitzgerald et. al 2008.  Boingo didn't just make up some harebrained mcguyver procedure, it's a recognized technique (albeit in hospital in this context).

Stupid - maybe for an EMT, dangerous - possibly, but likely less so than needle decompression, incorrect - not really.

To wit, some relevant excerpts: 

"Needle decompression of the chest is taught as a ‘life-saving’ procedure for patients in extremis with circulatory collapse secondary to tension pneumothorax.2 However, there is no evidence that needle thoracocentesis is a reliable or useful procedure for hospital trauma reception. Recent studies demonstrate significant failure rates associated with needle thoracostomy and the related technique of small gauge catheter-over-needle insertion"

"However, there is no evidence that NT is a reliable means of pleural decompression. The technique should be avoided during hospital trauma reception and resuscitation and used only as a technique of last resort. Blunt dissection and digital decompression should be the technique of first choice."

"However, blunt dissection and finger decompression appears to be a reliable and safe procedure and is the recommended procedure prior to chest tube insertion. Once successfully performed it reduces the urgency of the situation and allows time for the subsequent placement of a chest tube."


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## jrm818 (Dec 8, 2008)

Ridryder911 said:


> As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section).
> 
> R/r 911



What about EMS services that can insert chest tubes (I think they exist, especially HEMS...I may be wrong)?  From what I can tell digital probing (which will likely cause decompression) is used to insert the tube.  It would be approved for such a service, would it not?


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## Ridryder911 (Dec 8, 2008)

jrm818 said:


> :
> 
> "Needle decompression of the chest is taught as a ‘life-saving’ procedure for patients in extremis with circulatory collapse secondary to tension pneumothorax.2 However, there is no evidence that needle thoracocentesis is a reliable or useful procedure for hospital trauma reception. Recent studies demonstrate significant failure rates associated with needle thoracostomy and the related technique of small gauge catheter-over-needle insertion"
> 
> ...



Okay a little clarity! It does NOT state to place finger into the wound! It describes to perform a blunt or finger decompression.... hence puncturing or incising another opening for a chest tube. For those that really know treatment that is done by trocar or styllete and then a sterile gloved finger is inserted to relieve the pressure followed then by a chest tube. The lining of the pleura and the lining of the lung is felt. 

Again, not a simplistic and basic procedure.

The main problem I foresee is that this is a potential and negligent procedure. I am saddened that the moderators is still allowing this to even be discussed as a possible procedure to be performed by BLS and even ALS crews. I personally would hate to read where an EMT performed it as a last ditch procedure by reading this site.


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## stephenrb81 (Dec 8, 2008)

Up until reading this thread, I never had the SLIGHTEST idea there was a such thing as "digital decompression" for a tension pneumo.

Now, I am intelligent enough to know this is beyond my scope of practice and even if it was allowed, I am not trained and WOULD NOT attempt any maneuver based on an internet post/page/article without formal training.

Performing a medical procedure of any kind without formal training and beyond scope of practice is negligent in the U.S. Court of Law regardless if it "Saved a life".  (I am pretty sure inserting a finger into someone's chest cavity is considered 'invasive' and therefore is above an EMT-B scope of practice lol)

I have to agree with r/r 100%, this is interjecting an idea into someone's mind that may be very impressionable and they may try it one day, therefore this could be contributing to their negligence.

EDIT: I realize there has to be injury for a lawsuit, but "saving a life" still wouldn't apply in a civil suit because an EMT-B caused further injury attempting this (Further lung damage, infection, etc...)


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## jrm818 (Dec 9, 2008)

I never said the article said "put a finger in the wound."  That said, it seem to me that if there is already a sucking chest wound, digital decompression is possible without surgical dissection as there is already access to the pleural space - no need to make another incision.  Dirty and cowboyish? No doubt?  I suspect it would be effective in decompressing the chest nevertheless. 

I'm was not trying to defend the use of this technique in the field, only pointing out to those that have (in some cases I think unjustified) flamed boingo's proposed technique that it has a basis in clinical literature and would probably work. At some gross level a hole is a hole, and if it's big enough for a finger and accesses the pleural space, it should work.

As for the allowance of the discussion: why not?  Maybe it will spark discussion of the possibility of allowing it as an approved procedure (with proper training etc)?  If that's a stupid idea it will soon become clear through educated posters such as yourself.  That said the (small bit of) literature I've read about needle decompression suggests that that's not such a great technique.  Its certainly a debate to be had.

EDIT:

The notion that it is a bad thing to raise awareness among prehospital providers about techniques performed in a hospital strikes me as ludicrous.  Are you going to attempt open cardiac massage after hearing that some doctors do that?  If anyone is impressionable enough to attempt a procedure after simply reading about it on EMTlife.com they have wayyy bigger problems and don't belong anywhere near a patient.

Sorry, I'm of the opinion that education is a GOOD thing.  Learning about techniques in hospital can only increase a providers awareness of pathophysiology and treatment.  Some here didn't understand how opening of a chest wound could help a pneumothorax....I suspect they now not only know something about digital decompression, but also understand better the pathophysiology of pneumothorax as a whole (need to understand that to understand theconcept of decompression)

Third: Progress occurs by discussing ideas that are outside the box or are not in use now.  I don't see any reason that blunt dissection and digital decompression could not be taught as a prehospital treatment for pneumothorax...but in order for that to even be raised as a possibility the discussion needs to occur.


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## stephenrb81 (Dec 9, 2008)

jrm818 said:


> I never said the article said "put a finger in the wound."  That said, it seem to me that if there is already a sucking chest wound, digital decompression is possible without surgical dissection as there is already access to the pleural space - no need to make another incision.  Dirty and cowboyish? No doubt?  I suspect it would be effective in decompressing the chest nevertheless.
> 
> I'm was not trying to defend the use of this technique in the field, only pointing out to those that have (in some cases I think unjustified) flamed boingo's proposed technique that it has a basis in clinical literature and would probably work. At some gross level a hole is a hole, and if it's big enough for a finger and accesses the pleural space, it should work.
> 
> As for the allowance of the discussion: why not?  Maybe it will spark discussion of the possibility of allowing it as an approved procedure (with proper training etc)?  If that's a stupid idea it will soon become clear through educated posters such as yourself.  That said the (small bit of) literature I've read about needle decompression suggests that that's not such a great technique.  Its certainly a debate to be had.



I enjoy a good, mature, debate and I apologize if it appeared I was derogatory in any way.  I was criticizing but meant nothing harsh.  I try to maintain maturity when I debate (I won't admit to maturity among other matters lol).

Also, the phrase "Insert finger" was mentioned earlier in the thread, though it may not have been by you.

Again my apologies if it appeared I was attacking you.

EDIT:  My personal view on this subject is that a "maverick" procedure that is not part of the national curriculum was suggested and someone may one day attempt it without any training.  I am not debating the procedure itself, only that it isn't currently used in EMS in the USA.  I am for the introduction of new ideas and researching to better our profession but those ideas/research shouldn't be suggested to others as a currently accepted treatment plan in EMS


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## jrm818 (Dec 9, 2008)

the "insert finger" response was to Rid.  I was clarifying to him that I understood that the article I posted was talking about inserting a finger into a surgically created wound, rather than the sucking chest wound which presumably caused the pneumothorax in boingos hypothetical scenario, but that I believe the two techniques are equivalent enough that Boingo's procedure is not ludicrous (or stupid and incorrect).  

I didn't have a problem with your post except that i disagreed with it.  By contrast I did have a problem with some of the other responses to boingo which struck me as inflammatory and unproductive.  For clarity, the part of my last post in response to you is after the "EDIT."


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## stephenrb81 (Dec 9, 2008)

jrm818 said:


> EDIT:
> 
> *The notion that it is a bad thing to raise awareness among prehospital providers about techniques performed in a hospital strikes me as ludicrous.*  Are you going to attempt open cardiac massage after hearing that some doctors do that?  *If anyone is impressionable enough to attempt a procedure after simply reading about it on EMTlife.com they have wayyy bigger problems and don't belong anywhere near a patient.*



I believe in raising awareness in hospital techniques, I didn't mean to imply that I didn't

Unfortunately there are impressionable minds out there that hold an EMT-B license, I have worked with quite a few over the years among a few different services.  They will hear of a procedure or a way of doing something second-hand and believe, at face value, that they are capable



> Sorry, I'm of the opinion that education is a GOOD thing.  Learning about techniques in hospital can only increase a providers awareness of pathophysiology and treatment.  Some here didn't understand how opening of a chest wound could help a pneumothorax....I suspect they now not only know something about digital decompression, but also understand better the pathophysiology of pneumothorax as a whole (need to understand that to understand theconcept of decompression)



I agree with you. As I mentioned in previous threads, Me constantly bugging the ER doc, RN's, and Medics with countless questions that were beyond my scope of practice when I worked in an ER helped me soar through A&P, Medical terminology, Pharmacology, and strip interpretation in Medic School


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## TomB (Dec 9, 2008)

Ridryder911 said:


> The main problem I foresee is that this is a potential and negligent procedure. I am saddened that the moderators is still allowing this to even be discussed as a possible procedure to be performed by BLS and even ALS crews. I personally would hate to read where an EMT performed it as a last ditch procedure by reading this site.



Even if it worked and the patient lived?


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## Ridryder911 (Dec 9, 2008)

TomB said:


> Even if it worked and the patient lived?



Would you endorse such; if they performed a tracheotomy or pericardiocentesis, emergency C-section? All of those are "life saving" procedures that are essential as well. 

I still have NOT SEEN ANY CURRENT LITERATURE that endorse finger decompression as inserting into the wound. All of the finger decompression is still in regard to another surgical opening using a trochar or incision and ALL are still discussing the immediate following of chest tube placement. 

Again, it is not that I am against a procedure (even though this one has *yet* to be documented or discussed as introducing an nonsterile gloved finger entering into a wound. Now, please remember that one will have tissue fragmentation, possible broken ribs with the high potential of ruptured vessels, and more important dorsal nerve which is associated to intercostal movement. 

Hence the reason it is NOT taught in lieu of immediate decompression and the reason a chest tube is not inserted into the wound. If it was an ideal location then chest tube placement or decompression type devices would be much simple to insert. 

Again, we are discussing introducing a finger size opening into a wound. A wound that may be associated with fragments or even a much smaller than the size of a gloved finger, so we want to increase the size of the opening? Then followed by what? No further treatment is advised except to cover the wound. Alike needle decompression therapy the pnuemo will continue to increase as respiratory movement or ventilation occurs. Are you going to "burp" the dressing and re-insert the finger to decompress; since there is no further treatment? 

I believe we are missing the main point. There is reasons why this is NOT taught in the basic curriculum as well as even in the advanced area. The procedure as discussed (insertion of finger into the wound). Discussion of this procedure should be more debated after scientific studies and documented clinical performances. Then we should endorse or even criticize a medically proven procedure. For right now we are discussing a single procedure (as described) that I cannot find in current literature or texts.
R/r 911


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## boingo (Dec 9, 2008)

At the BLS level, you have no ability to decompress a tension ptx, we all know that.  The procedure I speak of was advocated by a group of trauma surgeons that teach ATLS that yes, we audit.  I've seen it work in real life.  Anecdotal?  Sure...I am not telling anyone to do it, all I did was mention a way to decompress a tension ptx caused by a penetrating chest injury without the use of a needle, scalpel, trocar etc... No one should be doing things outside there scope, but if a hypothetical patient were to arrest in the back of the truck without ALS available, and you have a 20 minute ride to the hospital, the procedure, although not approved, can be life saving.  The benefit in this particular situation, i.e. hemodynamic collapse and cardiopulmonary arrest outweighs any risk, i.e infection, damage to intercostal neurovascular bundle, viceral damage...  With that said, I'm not suggesting to anyone to go out and do it.

You mention prehospital c-section...it has been done, successfully even.  There are a few HEMS systems that can, and some ground systems in Texas I believe.  I don't advocate anyone doing this either, however just because its not allowed in the field doesn't make it not worthy of discussion.  There was a time when RSI wasn't allowed in the field, hell, it wasn't allowed by the ED, only anesthesia could do it.  Times change, medicine changes, figured it was worthy of "intelligent" discussion.  

I don't think we are missing the main point at all, the OP wasn't asking about EMT curriculum, he was asking for information from BLS and ALS providers, which he got.

I must say I'm glad to see a few see the point I was trying, apparently not very well, to make.


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## traumateam1 (Dec 9, 2008)

Ridryder911 said:


> *Would you endorse such; if they performed a tracheotomy* or pericardiocentesis, emergency C-section? All of those are "life saving" procedures that are essential as well.
> 
> I still have NOT SEEN ANY CURRENT LITERATURE that endorse finger decompression as inserting into the wound. All of the finger decompression is still in regard to another surgical opening using a trochar or incision and ALL are still discussing the immediate following of chest tube placement.
> 
> ...




I don't remember if it was Canada or the US where a doctor arrived on the scene of a nasty MVC and found that a lady wasn't breathing.. so using a swiss army knife and a straw I think? He gave this woman an emergency tracheotomy and saved her life. Heres the thing.. he was "off duty", didn't have the proper tools and resources and because he did what he did, it left scars on her neck. She sued the doctor and won. Sounds like a states thing.

I am not up for doing things that far out of my protocols, yes I will venture out a bit and say "oh I was using those critical thinking skills you taught us" or something along those lines, but I don't plan on doing something that drastic. This may sound harsh.. but we have to look our for #1 - ourselves first. Someone else's life isn't worth me losing my job, gaining a bunch of lawyer fees because my company and insurance no longer covers me, and losing my house/family/car etc etc. Yes that is kinda harsh, but if someone codes because of a bilateral tension pneumo.. I'm gonna work the code accordingly and let the ER staff deal with the pneumos. 
Just my .02


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## wbroemts (Dec 12, 2008)

you are right there was a time where rsi would have never been allowed.  Things do change and we will see what comes next.  Good point bingo!


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## Ridryder911 (Dec 12, 2008)

wbroemts said:


> you are right there was a time where rsi would have never been allowed.  Things do change and we will see what comes next.  Good point bingo!



Change always comes as well as events that repeats itself. Those things that do change is done with proven scientific studies and NOT anecdotal events. That is why PASG is no longer used, as well as many other procedures and techniques. Even RSI is being questioned if the dangers out weighs the benefits. It may not be to long from now as many may say... "remember when RSI".....


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## wbroemts (Dec 13, 2008)

Hello rr 911 I belive you are correct as well I understand as well where you are coming from.  You know as well as I do that everything gets questioned at one point or another that is the beauty of the medical field though it it always changes and never stays the same.


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## EMT-P633 (Dec 14, 2008)

boingo said:


> But as an EMT B there is no way to treat this patient.  The patient is in extremis and is going to die in short order.  Tension pneumothorax is a life threatening emergency, and since an  EMT B doesn't have the equipment or education to decompress a chest, the simple insertion of a finger, or opening the wound with traction can allow built up air to escape.  I don't advocate anyone going out there and doing it, don't advocate breaking protocal, just pointing out that there are techniques other than a large bore needle that can help alleviate tension pneumothorax.  I appologize to anyone who may have been given the impression that it was ok for them to try it tonight.



One thing you need to remember, besides everything Ridr has already said, "Not all of your patients are going to live. Some will die, some of them while you are looking them in the face saying I am doing all i can....."


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