Chest tubes

One of my favorite emergency room procedures is placement of a chest tube. The past week I've placed a number of them for developing tension pneumothoraces. Though I enjoy doing them now, I was petrified of learning the procedure as an intern.

Its a pretty straight-forward procedure that interupts a process that would result in the patient's death. The typical scenario is a patient who has been in a car wreck and has had significant force applied to their chest. Usually they have a number of broken ribs on that side in addition to the collapsed lung (pneumothorax).

A pneumothorax kills you fairly quickly if left untreated. You're lung is basically a big balloon comprised of a number of smaller balloons (alveoli). With blunt chest trauma, the lung is either punctured by broken ribs, or simply has a section that pops due to the rapid application of force after hitting the steering wheel or something. With each breath, air escapes out of the lung into the space between the lung and the thoracic wall. Each breath therefore collapses the lung just a little bit more. Eventually, so much air has escaped into the thorax that the lung is entirely collapsed.

What is lethal about a pneumothorax, though, isn't the collapsed lung. I have had several patients in whom we removed an entire lung for cancer, and they did just fine with one lung. Patients with a pneumothorax die because eventually the amount of air that has escaped into the pleural space is so great that it actually pushes the heart and veins that drain into it (superior and inferior vena cava) way over to the other side of the chest. Eventually things are pushed over so far that the veins are kinked to the degree that blood cannot return to the heart from the rest of the body. Your heart then has no blood to pump anywhere, and you die.

All this is stopped by making a several centimeter incision on the skin, dividing the underlying intercostal muscles between the ribs, and then putting a tube into the space between the lung and the chest wall. The air all comes rushing out, no veins get kinked, and another trauma patient is saved to eventually be released back into the wild.

Its a procedure short on technical skills (though you can actually kill someone during chest tube placement by doing something stupid like putting the tube into the heart) and high on immediate gratification.

Changing of the guard

This is always a melancholy time of year. As I mentioned in a recent post, it marks the changing of the guard. A graduating chief class is replaced by a group of newly minted doctors stepping into their roles as interns.

At the end of every year, we have a few parties to honor them. The best is the one at Dr Barker's house. He sets up a few tents. Dr Maxwell roasts the meat... usually an all night ordeal. Sometimes its a whole hog. This year it was a bunch of ribs. They were splendid. At some point the chiefs are presented with a bunch of gag gifts. All in all, its a relaxing celebration of the accomplishments of the graduating class.

Every year, it gets a little bit harder to see them leave. I've spent four years with these guys, and have come to really enjoy them. Aderhold has been the source of numerous "ader'isms" that have made it to this blog. He's the guy who explained that hill-billies are poikilotherms, hence the rise in summer time traumas. He's also the guy who explained why pens in the south are called "ink pens." (Done to distinguish them from hat pins, bobby pins, pig pens, etc). Its also impossible for the guy to talk without gesticulating. Hence, engaging him in conversation during an operation is not wise. He will be heading back to his home town in south Georgia.

Mauldin decided that surgery wasn't for him after all, and decided to do an anesthesia residency. I've admired his attitude this past year. His decision to not practice surgery did not turn him into a jaded, negative personality. He was still a good leader and example to the rest of us. He will be doing an anesthesia residency in Atlanta.

Koontz was the ultimate example of taking responsibility for your patients and making sure that they got the best. He is also a publishing machine, who has probably had more publications than any resident to complete this surgery program. He is heading to Emory in Atlanta for a pediatric surgery fellowship.

Green is from Louisiana. He was one of those rare people who derive a true, infectious, joy from doing surgery. He's the kind of guy whom you'd call in the middle of the night to tell him about some disaster of a patient needing surgery. His enthusiasm never waned. He was just a real pleasurable person to be around. He'll be moving to Kansas City, Missouri to practice trauma surgery.

If you want to see pictures of any of these guys, or any of the other people whom I work with, go to... http://www.utcomchatt.org/Dept/Surgery/surgery.asp?dpage=residents