Any way to secure a chest tube with instrument ties?

[Angry Birds]

So, everyone has a procedure they like least... Mine is the chest tube... I can obviously do them but I don't have the same comfort level as other procedures and certainly don't have it on auto-pilot, mostly because I feel like I didn't get enough practice in residency on real patients (which is something I'm kicking myself for) and now since I haven't had an opportunity to put one in during my year as an attending. I fear I won't get enough practice going forward, and practice on mannequins is not the same thing...

The part I dislike the most is securing the tube, due to needing to do surgeon's knots. Every so often I force myself to practice this skill at home, so I don't forget how to do these.

BUT, is there any technique to secure a tube with an instrument tie of some sort?

Stupid question I'm sure but doesn't hurt to ask... Thanks!

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[Groove]

Well, the good news is that of all the surgical techniques most resistant to skill loss over time, I find thoracostomy tube placement to be near the top. If you feel rusty, a good opportunity would be to sign up for one of the labs at say ACEP or another national/local conference. That's what I'm doing with the transvenous pacemaker lab. I really need a refresher on floating a pacer, so I signed up. They've got one on chest tubes and cric's, etc.. Otherwise, you could always ask the surgeons at your hospital if they have any thoracotostomy tube cases coming up and see if you could assist. I have no idea what kind of response you'd get, but it's a thought.

As for suturing. I use 0 silk and throw a stay knot... simple interrupted through the laceration adjacent to the chest tube, square knot, then cut the needle off. I then wrap the long ends round and round the chest tube and cinch it down and then tie another square knot. I will then either do the same thing on the other side, or do a horizontal mattress around the tube. Sometimes, I'll place the chest tube at the edge of the laceration and use the stay knot on the other side which presses it nice and firm against the edge and don't bother with the horizontal mattress. Everyone seems to have their own method but those work well for me.

 

[Birdstrike]

The part I dislike the most is securing the tube, due to needing to do surgeon's knots. Every so often I force myself to practice this skill at home, so I don't forget how to do these.

BUT, is there any technique to secure a tube with an instrument tie of some sort?

Of course. It's irrelevant whether you instrument tie or hand tie. You can do a surgeon's knot either way. Just stitch and knot until you're confident the tube won't move. It doesn't have to be pretty enough for a Vogue cover. There is no secret formula to this. Tying a knot in a way that will not provoke a grumpy surgeon to ridicule you, should not be causing more anxiety than cutting a hole in, and sticking metal into, a person's chest. If you can do that without killing 'em, I'm sure you're not going to kill them with a gimpy-looking, yet completely solid knot of some kind. I'm sure you're doing it fine. You're on your own now. Do it how you want, just be effective.

 

[Angry Birds]

Of course. It's irrelevant whether you instrument tie or hand tie. You can do a surgeon's knot either way. Just stitch and knot until you're confident the tube won't move. It doesn't have to be pretty enough for a Vogue cover. There is no secret formula to this. Tying a knot in a way that will not provoke a grumpy surgeon to ridicule you, should not be causing more anxiety than cutting a hole in, and sticking metal into, a person's chest. If you can do that without killing 'em, I'm sure you're not going to kill them with a gimpy-looking, yet completely solid knot of some kind. I'm sure you're doing it fine. You're on your own now. Do it how you want, just be effective.

But, how would I do it with instrument ties alone? Because you gotta wrap the tube many times and then tie it down to the tube. Can you do that with an instrument tie? (I'd have to try this on a mannequin I guess...)

 

[dchristismi]

Of course you can. 🙂

I use one-handed throws most commonly when wrapping presents. Once you've got the first throw in, you can instrument tie it if you want. And you can even instrument tie that one. Just try it. I throw a square knot first to make sure the biting suture isn't too tight, then wrap both ends around the tube several times and tie again, usually with a whole bunch of throws.

 

[Hair Police]

I learned how to do one handed ties specifically for these emergent and often bloody procedures where you need quick control. It isn't too hard to learn if you didn't in training - there's tons of YouTube videos.

There's lots of ways to secure these tubes. You can throw the suture, tie your loop, and then tie the end to the tube. You can do the reverse: You can tie the end of your suture to the tube (wrap the tube a few times and finish with a square knot), use the end with the needle to throw the suture in the patient, take off the needle, and then tie to the standing line.