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Patient Case Study:
Pneumothorax
David (Thomas) Owen
Saint Petersburg College

















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Patient Case Study:
Pneumothorax
I was bandaging a superficial laceration to a patients ankle from an axe in the Fast Track
section of the ED when a nurse I had met earlier poked her head in, relieved to have found me.
When you are finished here, come to trauma one. They are going to put in a chest tube and
this doesnt happen too often, she said hurried and exited. The excitement had rubbed off on me
and I tried to remain calm and finish the figure eight wrap pattern. I reassured the patient and
made it safely down to the other end of the ED as fast as I could. I felt like a fly on the wall
again. I was beginning to acclimate to this, being a student in a busy environment and watched
the vitals on the machine run. His pulse was elevated, O
2
was a little low but everything else was
within normal limits. The trauma room was alive with nurses, technicians and the doctor who
would be preforming the procedure. As I stood there I finally locked eyes with the patient. He
was in his thirties and tall but sort of diminutive in width. His muscles were wiry and stretched
across his body and as I looked him over I saw lighter skin where scars had formed, each about
one to four inches in length and not very wide. It was like someone had driven santoku sushi
knives in all over his body long ago.
He had been looking at me as I watched him and finally he asked, Whats up with your
uniform? I suppose I did look drastically different than all the professionals in the room. So, I
told him I was a student training for EMT. At this his eyebrows raised and a plethora of insight
fell out of his mouth as if rehearsed. He gestured at a huddle of three nurses at a piece of
machinery on the far table, See over there? Thats the machine that is going to fix me. See
these, he motioned across his left chest from subclavicular down to his back, theyre scars
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from this same procedure. He told me that he had not only had this happen before but that this
was his seventh time. I found a scholarly article on the schools website that said the same things
but with the magniloquence of a professional: Unrecognized or untreated tension Pneumothorax
results in death.[7] Therefore, immediate decompression of the pleural space without radiologic
verification is mandatory, before total circulatory collapse occurs.[13,14] Insertion of a large-
bore needle into the involved pleural cavity converts the tension Pneumothorax into an open one,
usually with immediate improvement. An intercostal drain should then be inserted. (Rafaely &
Weissburg, 2000)
He looked all sorts of pleased with himself as a patient turned teacher and even continued
on with his delineations, unfazed, as they began to raise his arms and bend him like Gumby into
different positions. He told me that this happens to people with his body type, tall and slender.
Sometimes a lung pops and because of how they are pressurized, air rushes out into the chest
cavity and causes pressure to build up around the lung resulting in a collapse. Im lucky I
guess, I remember him telling me, This is just a buildup of air, a pneumothorax. Sometimes
there is bleeding as well and it becomes a hemopneumothorax, try saying that five times as fast
when you have blood in your chest cavity. He was oddly calm and familiar with the whole
gambit of proceedings. Maybe due to repetition but probably due to the fentanyl injection in his
arm. Though, his lung had collapsed to almost 70%. To put this in perspective, Pnx [is greater
than] 20% of the pleural space, or increasing in size, or associated with pleural effusion, requires
intercostal drainage. (Rafaely & Weissburg, 2000). I noticed I was not the only student in the
room. At this time the doctor was instructing someone else in their early twenties about lidocaine
and which parts to numb so the patient would not feel anything. They had put water in the
machine that would slowly draw out the excess air and attached a small bore pigtail tube. This
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tube is preferable to the larger diameter one if possible because it is less invasive and I am told it
hurts less.
It was time to put the needle in. The student was going to do the whole procedure with
the doctor there at his side, ready to step in at a moments notice. The injections of lidocaine had
set in and properly numbed the area and there was an incision made at the intercostal space in the
upper left chest. Just a wince out of the patient as the scalpel opened his skin and the needle slid
in. At about an inch or so the needle stopped and the doctor jumped to it to correct the position.
After that things went smoothly. Upon asking another nurse about how the patient must feel
having the needle worked like that I was told that it was time sensitive and to get the needle in
was the most important. The library Atlas of Emergency Medicine backs this up, If there is no
immediate improvement, do not hesitate to place a second needle in the next interspace. A chest
tube should be placed immediately. (Knoop & Lawrence, 2010). Then, the machine hopped to
and started sucking out a little air at a time, measured by bubbles in the water at the machines
base. A few stitches went in to secure the tube and bandages went on to protect it. Well, thats
that, says the patient and he congratulated the team around him for another job well done.
He would remain there for a few days under observation in case of any complications. I
met with him later on break to go over things more thoroughly with OPQRST and a SAMPLE
history. He said he noticed it when he got up, the pain was no more than a four or five the whole
time with pain and a tearing sensation in his lower back. He had allergies to penicillin drugs and
was not on any medications. He had trouble eating lunch and nothing he did made it better and
certain ways he breathed or moved made it worse. It was not until after lunch that he called EMS
to pick him up and bring him to where I met him earlier.
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Bibliography
Knoop, K., & Lawrence, S. (2010). The atlas of emergency medicine. (3rd ed., p. 161). China:
The McGraw-Hill Companies, Inc.
Rafaely, Y., & Weissburg, D. (2000). Pneumothorax. American College of Chest Physicians,
Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE|A62495014&v=2.1&u=lincclin_stc&it=r&p=
AONE&sw=w&asid=ff2ec4d1a138efaaa16e18645b1c9f6d

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