Bilateral tension pneumothorax? Oh my!

[stephenrb81]

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

 

[jrm818]

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."

 

[stephenrb81]

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

 

[TomB]

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?

 

[Ridryder911]

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

 

[boingo]

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.

 

[traumateam1]

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

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

 

[wbroemts]

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!

 

[Ridryder911]

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".....

 

[wbroemts]

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.

 

[EMT-P633]

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....."