There’s lots of info out there on how to put a chest tube in. But what about on taking it out? There are a few nuances that you should be aware of so you can do this as quickly and complication-free as possible.
Have a look at this 5 minute video and let me know what you think. Please leave your comments on YouTube.
Your preparation. You should already have full personal protective gear on, right? Right? Your existing gear is just fine. You do not need to change to sterile gown and gloves. The time wasted is probably not worth the low risk of infection in the rare event that the mother survives.
You need at least one assistant, preferably two. They will pass you instruments and provide retraction. Continue CPR throughout the procedure.
At the same time, call your OB and neonatal colleagues, if you haven’t already. If you don’t have any at your hospital, don’t sweat it. If you do, don’t wait for them to arrive.
Patient preparation. Have someone quickly insert a foley catheter.
Do not use sterile technique. It just slows things down. The bladder needs to be empty so you can quickly and easily get to the uterus.
The procedure. Here’s the blow by blow:
Splash some betadine on the skin. The mother is probably not going to survive, so infection is not a concern.
Make a midline, vertical incision from mid-epigastrium to pubis. Extend down to the midline fascia.
Enter the peritoneal cavity near the umbilicus. Extend the incision along the full length of the skin incision using scissors.
Use the scalpel to make a 4cm vertical incision near the top of the uterus. Insert your 2nd and 3rd fingers into the uterus, directed downwards. Use them to protect the fetus from the scissors as you use them to extend the uterine incision downwards.
Rupture the membrane with a clamp and deliver the baby. Remember, the membrane is tough! Insert your hand deep into the lower uterus under the baby’s head. Flex the body as you gently push upwards to deliver the head first. Suction the mouth and nose, then deliver the shoulders and body.
Cut and clamp the cord. Hand off the baby to another team for suctioning and resuscitation.
Continue to try to revive the mother. If circulation is restored, move immediately to an OR for delivery of the placenta, control of the bleeding that was killing her in the first place, and hopefully, closure.
Here’s a video that shows how quickly the procedure can be done (with a few edits). Just watch the first 47 seconds!
Yesterday, I described a technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.
A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique.