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Pneumothorax, traumatic, due to a fall from a horse

2012-08-28

A Pneumothorax

I am standing in the hallway outside the emergency room, with a couple of nurses, chatting about something. It is mid-afternoon, and through the glass doors I can see the driveway shaded by the wall of the hospital, with the trees on the side of the driveway still in sunlight. The walls are red brick, looking older than the thirty years since the hospital was built. I can see part of the lawn, already turning brown with the approach of winter.

I can’t see the street in front of the hospital, but I know it is quiet and only a few blocks long. The prairie waits to swallow up anyone who ventures out on the two lane road that starts at the end of the street…there is thirty miles of empty highway before the next town. There aren’t even any fences between the road and the prairie, just a foot of gravel and a ditch. You can look out across the prairie and see nothing but rolling hills and sky on either side. Looking down the road, it dwindles away ahead of you with nothing out there in front of you but a fading dot.

Drive a couple of miles down that road and you will be lost in the immensity of prairie, with nothing behind you and nothing in front. You have to stay on the road. There is no way to tell where you are, or how far you have gone

An old station wagon is coming up the hospital drive; it turns around and backs up to the door. The driver gets out and frantically motions to us inside.

We come out through the glass doors as the driver is opening the back of the station wagon. Inside there is a woman lying on her back. The driver, a man in his forties, says “we were horseback riding and she was thrown off her horse into a tree. She hurt her shoulder really bad and now she can’t breathe.”

One of the nurses crawls inside the station wagon, and we all help to pull the woman out and onto a gurney. She looks pale, and her breathing is labored. We take her inside to the emergency room. The nurses undress her with difficulty; she moans and winces with any movement, especially when they try to take off her coat.

As soon as she is undressed, I order oxygen by face mask at fifteen liters a minute.

She is young, with long dark hair, and thin. Her lips look bluish, and her breathing is rapid and shallow. She responds readily to questions, but otherwise lies still and quiet, not wanting to move. Examining her, I find a developing bruise on her left supraclavicular area extending back onto the upper scapula and up onto her neck. Her shoulder joint is intact. It is hard to hear her breath sounds, especially on the left upper lung fields. Her heart sounds are rapid and regular, without any murmurs or extra sounds.

Looking around, I see the nurses are anxious and don’t know what to do. Their anxiety could be a pressure on me. I will show a calming and directive personality to deflect the pressure of their anxiety. This is clearly a serious case and I need them to keep their anxiety under control so they can help me.

I direct the nurses to take our patient into the X-ray room to shoot some films of her chest. Laying her on her side, we shoot a cross-table lateral view. In the dark of the small viewing room, the light shining from the view boxes is obscured by the films covering their surfaces. The films are thin and stiff, and make a peculiar rattling sound as they are shuffled around.

The X-ray technician and I stand looking at the film from her cross table lateral. I can see that there is an abnormally dark area over the patient’s heart, with a clear line between her lung and the air that fills her upper chest cavity. The air is much greater than the lung.

She has a large pneumothorax, the air pushing her lung down and shifting her heart towards the right side of her chest. There are fractures of the first and second ribs, jagged edges showing where her lung has been punctured. Air has leaked from the lung puncture into the potential space of the pleural cavity. The edges of the puncture wound act like a flap valve, increasing the pressure in the pleural cavity with each breath. Gradually the pressure shrinks the space available to the lung tissue. Compression takes over and the patient’s vital capacity shrinks.

Back in the emergency room, I am looking through the equipment the nurses have brought out. There is nothing that looks like the tools I would have used to insert a thoracostomy tube into her chest, and there are no tubes that look small enough. However, there is an old looking instrument that has a sharp pointed rod inside a tube with an oblique opening on the side, about four inches long. It was designed to puncture the abdomen to insert a tube into the bladder, but it looks like it would work to punch through the chest wall.

Since there are no thoracostomy tubes, I ask for their largest urinary catheter and one of the older nurses brings out a large red rubber tube in a sterile sealed bag of white paper and clear plastic. I have lidocaine two percent with epinephrine drawn up in a twenty cc syringe with a 5/8″ 25 gauge needle, plain lidocaine two percent, and an array of hemostats, probes, a number eleven scalpel, an automatic retractor that worked by screws, a pile of sterile 4 by 4s, and so on.

I try to reassure the patient, who is as anxious as the nurses and restless. She is looking paler, and her lips are definitely blue. Working quickly, I prep an area on her upper anterior chest wall and anesthetize the skin. I make an incision about two cm long transversely, just above her fourth rib anteriorly. Using the bladder puncture instrument, I push in just above the rib margin to avoid the nerves and artery running along the lower surface of the rib. There is a loud hissing sound as I push through the muscle and outer membrane over the chest cavity.

The air trapped in her chest cavity has escaped! The woman immediately looks better, and her breathing slows.  Her lips lose their bluish tinge.  She smiles at me.  I can feel the beating of her heart through the sharp pointed rod and I suddenly feel the fear that I might puncture her aorta as well.  I remove the bladder puncture rod.

I insert a Foley catheter into the wound and close it with a couple of sutures in the skin.  I attach a 60 cc syringe to the Foley and withdraw more air.  Meanwhile, the woman rapidly improves and her lips look pink again.  We continue her with oxygen by face mask but turn it down to eight liters a minute.

The head nurse hands me the telephone receiver.  It is the emergency room doctor on call at the hospital in Rapid City.  The distance is ninety miles.  I tell the doctor that I will be coming with the patient.  He doesn’t seem surprised.  I hand the receiver back to the head nurse and ask her to look for my new physician assistant.  He will be on call at our home hospital until I get back–probably about three and a half hours.  Likely no one will call on him for help.

The room is quiet and most of the nurses have gone back to what they were doing before.   They are no longer anxious; the crisis has passed quickly.  I step outside.  It is dark already, and it is getting cold.  The ambulance is slowly backing up to the rear entrance, making its steady beeping noise.

The ambulance crew consists of a driver and two attendants, one in front of the patient’s head, and one by the patient’s side.  I sit on the patient’s “other” side, her right.  There is no hurry and they haven’t picked up any anxiety from the nurses, so they take my presence without questions.

The ninety mile drive to Rapid City is completely uneventful except that I twice try to aspirate more air from the catheter inserted into the patient’s pleural cavity.  I obtain no more than ten cc’s each time.

At the hospital in Rapid City, the doctor on call puts the patient’s chest Xrays up on the screen in the doctor’s call room.  He is describing the pathology to a young lady in a white coat.  I introduce myself as the doctor who saw the patient out in the field.

He introduces me to the young lady; she is a resident from Denver who is rotating through the Rapid City emergency room.  She seems to feel that Rapid City is the town at the edge of the unknown wilderness.  She looks at me as if I am some kind of weirdo, working out there.

The patient’s Xrays show a classic pattern.  When the top two or three ribs are broken, there is a high risk of pneumothorax.  The emergency room doctor explains the pattern to the resident as I listen myself; it certainly seems reasonable that a first, second, or third rib fracture could be directly associated with trauma that could push the rib into the lung and provoke a pneumothorax.

I mention to the emergency room doctor that there were no thoracostomy tubes available, so I have used a Foley catheter.  He laughs, and so does the visiting resident.  I guess the Foley catheter is somehow humorous.  There is also the imputation that I am short on supplies, which is also humorous.

Before returning to the ambulance, the driver, attendants, and I go down to the cafeteria and get cups of coffee, loaded with sugar and cream.  It is late, almost nine in the evening.  When we open the side doors to the ambulance bay we feel a rush of chilly air.

Outside, the sky is clear and we can see the stars between the tall trees in the parking lot.  The temperature has fallen to forty-five degrees with a northwest  breeze.

We take the freeway out of Rapid City back towards Phillip.   There are almost no cars on the freeway at this hour.  There is a stillness settling down like a black, soft, felt curtain over the road.  Leaving the freeway for the final thirty miles, we take a two lane blacktop and meet no-one driving against us.

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