My First Chest Tube!

Yesterday I got to put in my first chest tube!!!! This is a really cool procedure (and much coveted by med students the world over) - partly because it gives you the ability to really help someone in just a few seconds, and partly because they're pretty dangerous if you miss. If you're a little overzealous you can stick it in the liver, through the lung and into the mediastinum (where the heart and the aorta are), and even into the lung on the other side, all of which don't help the situation. You put in a chest tube when a person either has blood or air in their chest. In either case, the water or air is taking up room that the lung needs to expand, and the tube helps suck both of them out. If the patient has air in their lung (a pneumothorax), you'll get a rush of air when you stick the tube into the pleural cavity (where the lung sits, which usually has a negative pressure - if air rushes out, you know that there was a problem there). If they have blood in their chest, you'll get a gush of blood into the tube. In my patient's case, he may not have had any blood in his chest at all, as we didn't get any blood (or air, for that matter) back after inserting the tube. We think radiology may have overcalled it.

But at any rate, now I can say I know how to put in a chest tube!!!!

It's kind of a brutal procedure, and it's always nice when the patient is unconscious (or sedated well) when you're putting a tube in. You make an incision in the mid-axillary line (kind of under the armpit), after numbing the skin in that area. You can't really numb the skin and the muscle between the ribs completely, but you just do the best job you can. Then you stick in forceps, and open them and use them to make a hole in the muscle & cartilage between the ribs. It's very important to go right on the top of the rib, as a triad of nerves, arteries and veins runs right under every rib, and if you lacerate those, you give the patient a hemothorax, instead of fixing one. Then you grasp the tube with a bigger pair of forceps and stick those through the ribcage and into the pleural cavity. This is where you listen/feel for a rush of air, or get a lot of blood coming out of the tube. Then you stick the tube in until you feel resistance (the lung), and then sew it in place, and tape it VERY carefully to the patient's chest. Below is a Google image I found of dummies they have that teach you how to put chest tubes in.

We don't have any of those at Grady.

Here is a picture I found of what the tubes look like after you put them in. I didn't put in a pigtail chest tube, but that's more or less what the tube I put in looked like.

It was an exciting day!!!