Chest decompression question

[clincomedic]

Ok , I'll start off with the call. in town two vehicle MVA. pt was hit in passanger door. pt had obvious broken clavicle. upon extrication one off duty medic thought there might be tracheal deviation. pt loaded and lung sounds were listen to by a student who stated absent in upper right side ( broken clavicale side). off duty medic stated he didn't think he could hear anything. My boss was on working with the fire department at the time and was standing at the door. never came in. pt was only comlaining of pain to shoulder. no SOB. vitals stable. breaths 20 non labored. O2 sats 97% room air. 99% 15L/NRB. my boss wanted me to pop his chest. I was the medic that was accutually on the truck. so it was my patient. I had not personally listened to the pt lung sounds yet. after we left I was able to listen. I heard decreased lung sounds and the trachea look like it was to the left. but his right shoulder was closer to midline than normal. still no problems breathing. so I did not pop him. upon arrival at the ED Doc checked the lung. sounds were decreased, but there. He was going to put in a chest tube but the xray came back and there was no pnuemo only the pt shoulder pressing on the lung. so good call righ?....no my boss believes i should have popped him. he has told everyone in the station and police department that I made the wrong call and he now questions my pt care. I believe that if i popped him i would have caused undue pain to the pt and possible other complications. My boss being the >>>UUMMM>> boss he is has yet to talk to me about this. He has only roasted me in the court of public opinion.

I guess my questions are ..Am I wrong or did I do right by not doing more harm than good? and How would you handle this situation?

[Kiwiology]

You were the treating officer of record, tell yoru boss to get bent I say.

[paramedicmike]

Why are you having such a hard time defending yourself here?

You listened. The boss didn't. You acted on your assessment findings. Your boss reacted to an assessment he did not complete. The doc at the receiving facility didn't believe there was need to decompress. Initial assessment findings by the receiving facility supported that position. That looks like enough to support your clinical decision to me.

You need to approach your boss about this with the above information. It would work better for you if you also had the support of the receiving physician...so go talk to him. Tell your boss you would appreciate it that if he had problems with you he discuss them directly with you. Discuss your decision and bring in the support of the doc.

You need to get on the stick with this because the boss is being a jerk. But he will win if you let him. Make notes of everything. That way if he continues down this road you have documentation to refer back to when you go talk to a lawyer about a hostile work environment.

And start looking for a new job.

-be safe

[medic82942003]

It all boils down to PT care comes first- also Do no harm to pt. 2 jobs ago my boss told me not

to discuss a girl who was working on a expired license. Called me at 2030 at night and chewed my butt. Told me I should shut up. I quit on the spot. Its a felony in my state to knowingly let someone work like this. Wouldnt do that again. Unemployed for 7 months afterward.

You did the right thing. Lots of monday morning quarterbacks out there. Your boss is suffering

from CRI-cranial rectal inversion. Plus he knows his pt care sucked on that call. He is afraid you

will call him out- he wants public opinion on his side. Cheers be safe.

Also it looks like my unemployment will never come to pass, if you quit do to hostile work envirement, you must give bosses chance to correct problem. IE it had to be a problem more than once. at least 3 occasions with time inbetween. Write everything down. Good luck. cheers.

Edited August 7, 2009 by medic82942003

[chbare]

Decreased sounds are not the sole reason for placing a dart. In addition, I dare say it would be unusual for a patients own respiratory effort to cause a tension pneumothorax. Positive pressure ventilation, a different story. Add into the mix an awake, alert, and non labored patient, and I say absolutely no indication for decompression existed based on the story presented.

Even if a pneumo was present, many pneumos will resolve without any specific treatment beyond monitoring, rest, and follow up.

Looking at the studies actually reveals that many people with out pneumos are darted and in many cases the needle fails to even enter the thoracic cavity. Especially with the anterior 2nd IC approach. You also have to consider potentially hitting critical anatomic areas like a subclavian vessel when you consider placing a dart. Not a benign procedure by any definition.

Take care,

chbare.

[tniuqs]

Decreased sounds are not the sole reason for placing a dart. In addition, I dare say it would be unusual for a patients own respiratory effort to cause a tension pneumothorax. Positive pressure ventilation, a different story. Add into the mix an awake, alert, and non labored patient, and I say absolutely no indication for decompression existed based on the story presented.

Even if a pneumo was present, many pneumos will resolve without any specific treatment beyond monitoring, rest, and follow up.

Looking at the studies actually reveals that many people with out pneumos are darted and in many cases the needle fails to even enter the thoracic cavity. Especially with the anterior 2nd IC approach. You also have to consider potentially hitting critical anatomic areas like a subclavian vessel when you consider placing a dart. Not a benign procedure by any definition.

Take care,

chbare.

Agreed in this post entirety, no compromise, no dart required ... AND CXR by MD stated no Tension Pneumo ... I would have the MD have a wee chat with your armchair boss .. he is slandering you.

Maybe dart him ? ... dang outside voice again.

cheers

[mobey]

Does anyone else hate the term "Dart him"

It sounds so juvenile.......

I rank it right up with calling an ambulance a "Bus" on my {Things that annoy me} scale.

[HERBIE1]

Your boss is wrong. If the person was decompensating- poor sats, hypotension, decreased mentation- then needle decompression is appropriate. Tracheal deviation is also a late sign of a tension pneumo so I doubt that was accurate. The person would be in severe respiratory distress by that time.

Possible reasons for the apparent lack of lung sounds- noisy scene, patient was hypoventilating- pain was keeping him from breathing deeply.

Putting a needle in this patient would be like defibirllating a wide awake, normotensive patient for an apparent V-fib on the monitor. Something else is going on.

Tough call as to how to proceed. If the boss pushes this, I would ask his clinical rationale for justifying what he wanted but I see no evidence he can support his claim.

If he continues, you can have the treating MD speak to him, but then you may be burning your bridges, challenging his authority, and it's probably time to leave. I'd wait to see how this plays out and then you can decide how far you want to push this.

Is there someone above this boss you can plead your case to?

Good luck.

Personally, I would confront the boss about his poor clinical and diagnostic skills and start looking for another job. He sounds dangerous. You do what you feel is right for you, but it's clear you have a major problem with this incident- and rightly so.

That's also easy for me to say- it's your job to lose, not mine.

[tniuqs]

Does anyone else hate the term "Dart him"

It sounds so juvenile.......

I rank it right up with calling an ambulance a "Bus" on my {Things that annoy me} scale.

Ok mobey suck it up princess ... history of EMS 101.

The BUS phraseology is limited to the Bronx, Manhattan and other burrows of NYC ONLY Richard B EMT if he would so desire to educate ..... well unless we are speaking of MCI BUS out of Dedmonton cause that is a Bus, and lots of elbow room too.

The term DART is one of endearment as the McSwain Dart has its roots deep in EMS History and Dr. McSwain was the innovator of PHTLS (just in passing) He was instrumental in obtaining a U.S. Department of Transportation grant to establish the state's first paramedic program. The program was coordinated through the School of Medicine's Department of Surgery, and McSwain became the first medical director for the state bureau of EMS. Since then, he's remained one of the nation's--and the world's--foremost figures in emergency medicine and trauma care.

http://www.stouts.org/jack/EMS/JEMS1283v2.htm

http://www.ncbi.nlm.nih.gov/pubmed/7176990

http://www2.tulane.edu/article_news_detail...?ArticleID=4231

BUT the best

IMHO

in decompression of a tension Pneumothorax for the ALS provider is not a improvised "finger of a sterile glove" or the Hind Lick valve which is a joke "Duck Call"!

SOP with the US Marines Medics, is a 4 inch 10 gauge cath, and punched through Chest wall and landmarked with the use of betadine and use "non ribbed condom" ps its not her pleasure I am concerned with, then a 10 cc syringe filled with N/S attached and the plunger almost popped out of the Syringe, not only does this serve well as a cost effective device for decompression of a Tension Pneuomo and I SO love to send the requisition to "supply".

btw (rolled up ring and ring cut off) and LONG enough (see chbars comments) re: screw ups and (insulated chests or the Neanderthal chest syndrome) the Asherman drain is fine for BLS if your dealing with penetrating GSW of the Knife Club membership holders here.

It is a great visual conformation (ie the bubbles) and very effectively implemented in areas of high abiant noise i.e Industrial racket or small arms fire as a visual reference.

A real CT is the cats ass, when you do have CXRay available.

cheers

[letmesleep]

I'd have to agree with all the other responses, it sounds like you made the correct decision based off of your assessment. Sounds to me that your "boss" (for lack of a better term) had some tunnel vision, based off the statements of an off-duty medic who wasn't even sure of what he/ she was hearing. Talk to the MD and follow up with this "boss" to get things cleared up, we all know how hard slanderous statements can kill your reputation, and unfortunately that can destroy a career.

The "boss" has NO right discussing this issue with others.