Chest Tube and Procedure Protocols

[Darth Doc]

Our residency program doesn't have a written chest tube or trauma procedure protocol, and we're interested in developing one. For those of you who know about EM programs at Level 1 Trauma centers where ED residents and surgery residents need the same ACGME procedures, what protocols do those programs have? For example, University of South Georgia - ED resident gets left-side chest tubes, trauma resident gets right-side chest tubes. Is the protocol written or is it a verbal understanding between ED and surgery? I'm trying to get some basic (non-validated) data to give us some leverage to improve our current process.

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[migm]

really depends on your institution. EM residents are on trauma service for months where I came from and does the procedures. other places have EM do it some days and trauma others..

 

[alpinism]

Sorry but this is bullsh*t.

Here’s your trauma procedure protocol:

Emergency residents do the emergency procedures in the emergency department.

 

[gamerEMdoc]

Typically if its a chest tube in the trauma bay, then someone on the trauma team does it (may be a EM resident on the trauma service or a surgery resident on the trauma service).

If a patient comes into the ED (not trauma bay) and needs a chest tube, typically the ED does it.

 

[BoardingDoc]

Our residency program doesn't have a written chest tube or trauma procedure protocol, and we're interested in developing one. For those of you who know about EM programs at Level 1 Trauma centers where ED residents and surgery residents need the same ACGME procedures, what protocols do those programs have? For example, University of South Georgia - ED resident gets left-side chest tubes, trauma resident gets right-side chest tubes. Is the protocol written or is it a verbal understanding between ED and surgery? I'm trying to get some basic (non-validated) data to give us some leverage to improve our current process.

For trauma activations:
Even days: trauma does procedures
Odd days: EM does procedures
EM does airway. Always.
For any procedure done in the ED that the trauma team was not paged for: EM does all of it. E.g. if you have a spontaneous PTX, and it's an even day, that's irrelevant. It isn't trauma. The ED does the chest tube.

 

[John Red]

For trauma activations:
Even days: trauma does procedures
Odd days: EM does procedures
EM does airway. Always.
For any procedure done in the ED that the trauma team was not paged for: EM does all of it. E.g. if you have a spontaneous PTX, and it's an even day, that's irrelevant. It isn't trauma. The ED does the chest tube.

This is identical to how we run it: even/odds split between procedures/trauma captain

Occasionally for critical activations gas will show up and be designated “airway” although I have NEVER seen them intubate the those patient’s, they always say “If you want it I will be here for backup...”

EM/Trauma has a good working relationship given our odd/even split because it takes the guess work and bickering out of it, although we all moan when a certain attending gets hyped and takes the procedures

 

[southerndoc]

There is no such thing as the University of South Georgia. Do you mean University of South Alabama?

 

[Darth Doc]

There is no such thing as the University of South Georgia. Do you mean University of South Alabama?

No. I made it up. Although I know that U Missouri does the left/right side method.

 

[Fox800]

Even/odd days.

In reality: page trauma team as the EM resident is making the incision.

 

[Tenk]

Typically if its a chest tube in the trauma bay, then someone on the trauma team does it (may be a EM resident on the trauma service or a surgery resident on the trauma service).

If a patient comes into the ED (not trauma bay) and needs a chest tube, typically the ED does it.

This is how it was for us.

I actually managed to sweet talk my way into doing a chest tube on my cardiology month. We had a patient with a pneumo s/p pacemaker. Fun times.

 

[Lexdiamondz]

For trauma activations we do an even - odd system with EM always doing airways and thoracotomies/REBOA always going to surgery.

For atraumatic PTX requiring chest tubes these go to EM

All other departmental procedures (intubation, central lines, paras, thoras, etc) go to EM.

 

[Groove]

If you've done one chest tube, you've done 1000. Of all the EM procedures, this one suffers the least amount of skill atrophy. If you end up graduating and are worried that you haven't gotten enough of these, you'll be just fine. It's not rocket science.

In our residency, I think we did even/odd days. I can't remember any more. It seems like there were plenty of these to go around though.

 

[Lexdiamondz]

If you've done one chest tube, you've done 1000. Of all the EM procedures, this one suffers the least amount of skill atrophy. If you end up graduating and are worried that you haven't gotten enough of these, you'll be just fine. It's not rocket science.

In our residency, I think we did even/odd days. I can't remember any more. It seems like there were plenty of these to go around though.

I dunno if I agree with this 100%. my first chest tube on an obese person was tricky to say the least - and this was after having done >10 already. Finding landmarks and knowing how big to make your incision and how deep to cut still takes a learning curve - as is troubleshooting if you nicked an NV bundle on the way in.

 

[Groove]

I dunno if I agree with this 100%. my first chest tube on an obese person was tricky to say the least - and this was after having done >10 already. Finding landmarks and knowing how big to make your incision and how deep to cut still takes a learning curve - as is troubleshooting if you nicked an NV bundle on the way in.

It's really the simplest of procedures. Common mistakes are not making the incision wide enough and not dissecting far enough in an obese pt. Don't saw down between ribs with a scalpel (will cut neurovascular bundle). Don't go too low (diaphragm is always higher than you think). Using trochars can also get an overly enthusiastic doc into trouble (which is why I never use them after an ICU attending spear fished a pt's left ventricle). Being careful not to punch the tube through a large bleb, etc.. But at the meat of it....the anatomy is very very simple. Dissect...brace thumb at base of forceps so you don't go too deep and punch through, dilate, insert the tube, secure, water seal, connect suction, check for leaks. The only tube thoracostomy I ever found remotely challenging was a 6yo tension PTX that I put a chest tube through his 1st and second rib in the heat of the moment as a PGY2. To each their own though.

 

[gamerEMdoc]

I agree that its really not that difficult of a procedure, and tubes like the thal-quick make it even easier.

 

[The Knife & Gun Club]

It was such a culture shock when I went on aways to see EM have any involvement in trauma at all.

At my home program EM has no involvement in trauma activations - trauma goes to a separate center run by surgeons. EM residents rotate through trauma service but are not allowed to perform airways or any procedures on those months, just fast exams and document.

 

[DrDrummer]

At my home program EM has no involvement in trauma activations - trauma goes to a separate center run by surgeons. EM residents rotate through trauma service but are not allowed to perform airways or any procedures on those months, just fast exams and document.

Where was this and how are they allowed to have a residency? San Diego or Maryland? That sounds like a painful month-long rotation.

 

[Rendar5]

I only did 3 in residency when I competed with surgery residents and have done scores as an attending. Once I got my 3rd tube in it was a proficient skill unlike most other procedures that took much more time to develop proficiency.

 

[Buckeye1992]

Any of you guys put in thora vents for PTX? I tried these out recently and they are super easy.

We are small and a level 3 trauma center so we do all of our own procedures.

 

[CliveStaples]

Very surprising to see how little EM seems involved in traumas at a lot of programs. I'm in my last year at a program at a level 1 trauma center and we have two levels of trauma activations. The highest ones (I.e. hypotensive), the procedures are split between the Trauma resident (which 50% of the time is an ER resident on the Trauma service) and the ER resident after he/she has managed the airway. I say split not because we actually keep track but because in many of these resuscitations there are multiple procedures that need to happen in parallel so both of them are doing it. In lower level trauma activations and in every other patient that comes into the trauma bay that isn't a trauma activation, there is no place for the trauma team to preform a procedure.

 

[mega_colon]

I’ll give a plug to buddying up with your trauma residents. We have the same split sharing based on what hour of the day we are in, but in reality most of the trauma residents have met their numbers and since we are all friends they don’t care who does the chest tube. That has netted me quite a few tubes I wasn’t technically supposed to do based on the service agreements.

Also agree, airways and lines take practice, chest tubes are an easy skill and the life saving intervention is venting the chest, once you’ve vented you have all the time in the world.

 

[KGflyboy]

EM resident takes airways.

Trauma resident does the other procedures.

EM residents do rotate through the trauma service and occasionally do the chest tubes and other procedures, but typically the surgery residents on the trauma service keep those for themselves.

 

[littlejuan]

For trauma activations:
Even days: trauma does procedures
Odd days: EM does procedures
EM does airway. Always.
For any procedure done in the ED that the trauma team was not paged for: EM does all of it. E.g. if you have a spontaneous PTX, and it's an even day, that's irrelevant. It isn't trauma. The ED does the chest tube.

that’s how we did it. This included thoracotomies. We had tons of trauma though so that was fine. If you don’t get tons of trauma I feel like the ER should get all the procedures.

 

[askamsky51]

We have a protocol on paper that no one pays attention to. Our surgical service is overwhelmed and always has at least 1 EM resident on anyhow.

Chest tubes goes to whoever asks for it, tbh. There's enough to go around and we play well in the sandbox.
We have a great relationship with our surgeons, which helps. Typically though we defer it to the resident on TICU (especially if it's one of ours).

This obviously doesn't work everywhere but figured i'd weigh in to counter the lack of ED hands on other places. thoracotomies typically go to the senior surgery resident but if the R4 is ready to cut when the patient rolls in or codes they often let us have it.

That being said -- to all the MS4's out there reading this... Trauma isn't all it's cracked up to be. I didn't believe it when I was in your shoes, but it's the truth.