All posts by TheTraumaPro

Flying Or Diving After Traumatic Pneumothorax: Part 2

Yesterday, I wrote about the accepted management of and delay in flying due to traumatic pneumothorax. I republished the post because of the very recent acceptance for publication of a paper from Oregon Health Science University in Portland. The authors specifically tried to assess timing of chest tube removal and long-distance flight, and to measure the risk of pneumothorax recurrence or other complications.

The authors performed a retrospective review of a series of military patients who had sustained chest injuries that were treated with chest tubes over a 5 year period from 2008 to 2012. After tube removal and a pneumothorax-free period of at least 24 hours (by chest x-ray), the patients were then transported by air from the military theater back to the United States.

Here are the factoids:

  • Of 517 patients screened in the military trauma registry database, only 73 were available for study after applying exclusion criteria
  • Subjects were predominantly young and male, as one would expect from the injured military population, and 74% were injured by a penetrating mechanism
  • Median time that the chest tube was in place was 4 days, and median time from tube removal to flight was 2.5 days
  • All patients had post-flight documentation available for review, but only half (37) had in-flight documentation available
  • Nearly half (40%) had positive pressure ventilation in place during the flight
  • Five patients had “in-flight medical concerns” (4 were ventilated), but none were related to the pneumothorax. The four ventilated patients had ventilator issues, the non-vented patient had “self-limited discomfort without evidence of respiratory distress.”
  • None of the subjects developed a recurrent pneumothorax, either post-flight or over the following 30 days

The authors conclude that air travel after tube removal and a 24-72 hour observation period “appears safe.”

Bottom line: Not so fast! This is yet another small, retrospective study making grand claims. The study group is a very unique population: healthy, fit young men with penetrating injury. Your average civilian trauma patient is older, less healthy, and usually has a blunt mechanism with multiple rib fractures. In-flight documentation was not available in half of the cases. And a full medical team was present on the aircraft had a problem actually occurred.

Contrast this with a civilian patient on a commercial aircraft with very limited medical equipment and expertise on board. What could go wrong? I definitely do not recommend changing our practice on these patients yet based on this one paper. Until we have better guidance (more good papers) stick to the usual wait time to ensure a safe flight for your patient.

Reference: Trauma patients are safe to fly 72 hours after tube thoracostomy removal. J Trauma, published ahead of print, May 18 2018.

Flying Or Diving After Traumatic Pneumothorax: Part 1

Today, I’m dusting off an old post on flying and diving after pneumothorax. This shows the thinking up until last year. Tomorrow, I’ll write about a new paper that suggests that we can shorten the “no-fly” time considerably.

Hint: no changes to the diving recommendations. One pneumothorax is likely to ground you forever.

Patients who have sustained a traumatic pneumothorax occasionally ask how soon they can fly in an airplane or scuba dive after they are discharged. What’s the right answer?

The basic problem has to do with Boyle’s Law (remember that from high school?). The volume of a gas varies inversely with the barometric pressure. So the lower the pressure, the larger a volume of gas becomes. Most of us hang out pretty close to sea level, so this is not an issue. But for flyers or divers, it may be.

Flying

Helicopters typically fly only one to two thousand feet above the ground, so the air pressure is about the same as standing on the earth. However, flying in a commercial airliner is different. Even though the aircraft may cruise at 30,000+ feet, the inside of the cabin remains considerably lower though not at sea level. Typically, the cabin altitude goes up to about 8,000 to 9,000 feet. Using Boyle’s law, any volume of gas (say, a pneumothorax in your chest), will increase by about a third on a commercial flight.

The physiologic effect of this increase depends upon the patient. If they are young and fit, they may never know anything is happening. But if they are elderly and/or have a limited pulmonary reserve, it may compromise enough lung function to make them symptomatic. And having a medical problem in an aluminum tube at 30,000 feet is never good.

Commercial guidelines for travel after pneumothorax range from 2-6 weeks. The Aerospace Medical Association published guidelines that state that 2-3 weeks is acceptable. The Orlando Regional Medical Center reviewed the literature and devised a practice guideline that has a single Level 2 recommendation that commercial air travel is safe 2 weeks after resolution of the pneumothorax, and that a chest x-ray should be obtained immediately prior to travel to confirm resolution.

Diving

Diving would seem to be pretty safe, right? Any pneumothorax would just shrink while the diver was at depth, then re-expand to the original size when he or she surfaces, right?

Not so fast. You are forgetting why the pneumothorax was there in the first place. The lung was injured, most likely via tearing it, penetration by something sharp, or popping a bleb. If the injured area has not completely healed, then air may begin to escape through it again. And since the air used in scuba diving is delivered under pressure, this could result in a tension pneumothorax.  This is disastrous underwater!

Most injuries leading to pneumothorax heal completely. However, if there are bone spicules stuck in the lung or more complicated parenchymal injuries from penetrating injury, they may never completely heal. This makes the diver susceptible to a tension pneumothorax anytime they use their regulator.

Bottom line: Most patients can safely travel on commercial aircraft 2 weeks after resolution of pneumothorax. Ideally, a chest xray should be obtained shortly before travel to confirm that it is gone. Helicopter travel is okay at any time, since they typically fly at 1,500 feet or less.

Divers should see a physician trained in dive medicine to evaluate their injury and imaging prior to making another dive.

Tomorrow: new info on flying after pneumothorax

References:

  • Divers Alert Network – Pneumothorax – click to download
  • Practice Guideline, Orlando Regional Medical Center. Air travel following traumatic pneumothorax. October 2009.
  • Medical Guidelines for Airline Travel, 2nd edition. Aerospace Medical Association. Aviation, Space, and Environmental Medicine 74(5) Section II Supplement, May 2003.

Last Chance To Complete The ED Thoracotomy Survey!

The number of new survey completions is starting to dwindle, so I will be closing the ED thoracotomy survey this Friday at midnight Central time. I’ll pick apart the results and publish them in the next couple of weeks.

I am trying to determine who could and who actually does perform ED thoracotomy across the various trauma hospitals around the world. For those of you who have already completed it, thanks! For everyone else, please take the 2 minutes to finish it soon!

Click here to take the ED thoracotomy survey.

Thanks,
Michael

Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

How To Design Your Trauma Bay

I spent the last two posts discussing the size of your trauma bay and how to measure it. This can obviously be helpful if you are updating or building new resuscitation rooms. But what about all the stuff that goes into it? Where is the best place to put it? If you are in the enviable position of being able to stock a brand new room, here are some tips.

Figure out what you really need in the trauma bay. You don’t have to put everything and the kitchen stove in there. It’s fine to have less commonly used equipment somewhere else, but it must be close! You don’t want someone to have to walk 50 yards to look for something you need right now.

Here’s a list of the critical stuff:

  • Temperature and light controls.  These must be inside the room for easy and rapid access. And the doors should close to contain the heat. Resus rooms that are used frequently should be kept warm, doors closed, at all times.
  • Personal protective equipment. This should be located just inside the room (if space is available) or just outside. It absolutely must be near the entrance and easily accessible or no one will wear it.
  • Airway cart and video laryngoscope. These items must always be located near the head of the bed for immediate availability.
  • Difficult airway cart. These are not used frequently, so need not be placed inside the room. But make sure it is close by.
  • Travel ventilator. This can be stored outside unless you have lots of space available.
  • IV start/blood draw carts. One of these should be stationed on either side of the patient.
  • Rapid infuser. This may be located inside or outside of your trauma room based on the number of times it is typically needed.
  • Procedure packs. These should be located inside the trauma bay, and clearly organized inside cabinets.
  • Medication dispenser. This must be inside the room. Period.
  • Other commonly used equipment/supplies.  These should be placed intuitively in the bay and/or cabinets depending on frequency of usage of each item. Clear marking is essential.
  • Scribe stand. Don’t forget the scribe. They obviously have to be in the room, and need some space for the (preferably) paper trauma flow sheet.
  • Pediatric cart. This can be stored inside or outside the resus room, but should be nearby. Make sure that the measuring card that translates child size into equipment size is easily located.
  • Blood refrigerator. This item is optional, but is becoming more common. It can be located inside or close outside the trauma bay depending on space available.
  • Blanket and sheet warmer. These are nice to have, wherever you have room to put one. The patients will appreciate it.
  • Procedure lights. Ceiling mounted are best because they don’t take up floor space. However, these are notorious for developing a mind of their own as they age. After a while, they never seem to stay focused on your field.
  • Forced air warming blanket unit. This is important here in Minnesota, but also anywhere your patients can get cold. Which is pretty much everywhere. The airflow unit itself is relatively small and can usually be tucked under a counter somewhere. Otherwise, keep it nearby.
  • Linens hamper. You need to get rid of that gown / those sheets and blankets / or whatever. There’s no reason to take up space in the room for this. Park it outside.
  • Laundry basket. This is a valuable item that is generally overlooked. What do you usually do with all that stuff you cut off the patient? Drop it on the floor, right? This is setting you up to lose your patient’s stuff. Get a cheap plastic laundry basket from Target and put it under one of the counters. Toss clothing, shoes, etc in it as they are removed.
  • Cast cart. These are typically huge. They can be anywhere else but inside the trauma bay. Roll it outside the door when needed.

Now where do you put all this stuff? Most trauma centers already have an established layout and flow in their existing trauma bays. When you are moving to a new one, plan ahead! Hopefully you will have more room, so you’ll have some additional flexibility as to where to place everything.

But designing the placement and flow on paper alone is of limited use. You must try it out in advance! How do you do this? Have your contractor mock up a space exactly the size of your new resuscitation room. Move actual carts, cabinets, and equipment into it. If it’s not possible to cart the exact stuff into it, have the contractor build mock-ups of them and place them in the bay.

Now have actual trauma team members practice simulations of common types of resuscitation: basic no frills, basic with intubation, basic with splinting/casting, advanced with all of the above plus multiple procedures. Take careful notes of flow and any glitches that arise. Then move your stuff around to fix any problems, and try again!