Take your paddle (bougie) up the creek!

Monday, December 23rd, 2019 | Rory | No Comments

Up the creek with a paddle!

Johnston TM, Davis PJ. The occasional bougie-assisted cricothyroidotomy. Can J Rural Med [serial online] 2020 [cited 2019 Dec 23];25:41-8. Available from: http://www.cjrm.ca/text.asp?2020/25/1/41/273534

Hopefully not a very frequently required procedure but a nice, easy to follow description – for when the time comes on the side of road or in hospital.

You can download the ‘blueprint’ and  print a 3D larynx to practice on. 

open access (html version – pay for PDF).

 

Interested in medical workforce/education research?

Thursday, December 19th, 2019 | Rory | No Comments

Interested in medical workforce/education research?

 

A team of supervisors from Auckland and Otago Universities is currently looking for Masters and/or PhD students to work with the MSOD project.

Introduction

About half of doctors make career decisions in the early postgraduate years, rather than during medical school. But we are aware from the international literature and our own research on Otago and UoA MBChB graduates that there are multiple factors that influence decision making starting with who is selected to become a medical student. Currently there is a mismatch between what doctors might decide as a career and the health workforce needs of Aotearoa New Zealand.

The Medical Schools Outcomes Database (MSOD) is a national longitudinal project collecting information on intended career choices and locations.  Medical students are surveyed at entry to and exit from medical school and graduates are surveyed 1, 3, 5 and 8 years after graduation.  Included in the surveys, are 24 questions that ask about influences on career choices – respondents are asked to rate these in importance.

Aim

To better understand what factors influence the career decisions recently graduated doctors make. (using the database).

If you might be interested I can provide further information and contacts.  garry.nixon@otago.ac.nz

The best not quite there yet…

Tuesday, November 19th, 2019 | Rory | No Comments

Hutten‐Czapski P. Is Northern Ontario School of Medicine there yet? Can J Rural Med 2019;24:103‐4.

Full text available at the CJRM website

This editorial is in the latest edition of the Canadian Journal of Rural Medicine. The Northern Ontario School of Medicine is considered the gold standard in rural medical education. But it appears that rural communities in Northern Ontario are still more likely to see medical students than the finished product, and most of the graduates are still headed to the cities; albeit the provincial cities in Northern Ontario.

This tells us what we already know. It’s not easy, and it’s important not to confuse workforce success in provincial centres with success in rural areas.

I am however sure we still have much to learn from NOSM.

Thanks to Assoc. Prof Nixon for the commentary

Rural and Remote – making it work: Learning from our Euro colleagues

Tuesday, October 29th, 2019 | Rory | No Comments

Making it work
open access
Longer and summary documents available

Taking the long view is essential

Some good stuff in this document. NZ has some of this in place, but tying it together without extra investment hard.

Plan/Recruit/Retain

  • Intersectoral investment in training and career promotion
  • Create desirable workplace
  • Create and incentivise a pool of transient workers to make a longer term commitment to your region

Plan/Recruit/Retain

Thanks to Fiona Doolan-Noble for the link

 

The Orange Declaration

Monday, October 21st, 2019 | Rory | No Comments

Perkins D, Farmer J, Salvador‐Carulla L, Dalton H, Luscombe G. The Orange Declaration on rural and remote mental health. Aust. J. Rural Health. 2019;00:1–6. https://doi. org/10.1111/ajr.12560

Open Access: https://onlinelibrary.wiley.com/doi/full/10.1111/ajr.12560

Contribution by Dr. Fiona Doolan-Noble

The Orange Declaration on rural and remote health evolved out of a meeting in Orange, New South Wales in October 2018 between mental health researchers and service providers from New South Wales, Victoria, the Australian Capital Territory and Western Australia to examine the issue of rural mental health and well‐being. Following the meeting five iterations of the document were developed, with participants agreeing upon a consensus statement that outlined ten problems related to current models of rural mental health and well‐being and ten potential solutions to the problems.

Reading the paper the identified problems and associated solutions could easily be applied to any health and social care service. As the authors highlight this is driven by the association and relationship between the challenges associated with provision of services in rural areas- geographical, demographic, social, economic and environmental. All of which are not addressed satisfactorily by the current mix of services, the distribution of the health and social care workforce, nor the associated skill mix within those workforces.

Sadly what is missing from the Declaration is any mention of the need to prioritise addressing the crisis in Aboriginal and Torres Strait Islander mental health and well-being.

The publication of the Declaration is a useful way to start a conversation about rural mental health and well-being and as a strategy for bringing the varied organisations and academic institutions working in the space together. However, it is to be hoped that any funding secured will be used in the first instance to co-develop programmes and interventions that are culturally appropriate for rural Aboriginal and Torres Strait Islander people.

 

“4 TEN PROBLEMS

Ten problems related to current models of rural mental health and well‐being were identified. They are as follows:

  1. Rural communities are different from cities and are not homogenous: they are distinctive, each with different local assets and challenges. Community contexts can change rapidly due to economic instability, dependence on particular leaders or natural disasters. One‐size‐fits‐all service models that cannot adapt to time, place and context are therefore inappropriate.
  2. The rural mental health system is not working: Indicators of rural health and illness suggest that current service models are failing, not fit for service or overly stretched; this situation has been recognised in the public imagination, the media and in political debate.
  3. Top‐down service models are based on urban assumptions: Rural service models in Australia are based on large region‐wide analyses of service activity data, with relatively little evidence of community co‐design or co‐production. People in rural communities can draw on available local evidence and participate effectively in service design. This requires providing them with appropriate data so that they can partner with local providers and commissioners. An example of these productive partnerships is the rural and remote Aboriginal Community Controlled Health Services that provide integrated and locally managed services which have achieved notable health gains.
  4. Services are not based on needs: Emerging evidence suggests that service provision does not always map to population need, nor does spending necessarily achieve better mental health outcomes. This suggests that the available services are failing to provide what is needed and could be due to demand exceeding supply, service fragmentation, challenges in service navigation or services not reaching vulnerable rural clients.
  5. The current forms of public financing are misaligned disproportionately rewarding outreach, telehealth and city‐centric models at the expense of the local public, private and NGO services from medical, allied health, nursing, peer and care partners. Short‐term funding constraints such as 12‐month contracts offered by Primary Health Networks discourage providers from making investments in rural and remote communities.
  6. Fragmentation and competition hinder sustainable, robust service provision: With a large number of service providers in small communities competing for short‐term contracts, addressing different performance targets and often based elsewhere; the role, past performance and track record of services can be highly confusing and their work uncoordinated. Navigating fragmented services increases transaction costs is a challenge for both clients and for health practitioners.
  7. Structural inequity in mental health service provision is amplified in rural areas: While there are rural residents with acute mental health needs, many of the current gaps in rural mental health might lie in areas of awareness, acceptability, prevention, mental health literacy and social connectedness. An over‐emphasis on specialist and hospital services neglects the first‐line “self‐care” that community members could provide for themselves.
  8. The rural mental health workforce cannot be a miniature version of that found in large cities. Its location, skills, scope of practice, supervision, support and development are all problematic. Mental health jobs are very demanding, responses are needed around the clock, personal and professional boundaries are hard to maintain in small communities and burnout is common.
  9. While telehealth and online services should augment mental health services for all clients whether rural or urban, people with mental health challenges often need to speak in person with a health professional, and on some occasions, very quickly. Rural residents need a range of appropriate options to cater for the different situations in their lives.
  10. Data sets are incomplete, disjointed and limited: many different and incompatible data sets are gathered and there is little data‐sharing or linkage. It is therefore complex to analyse service data and find out which services are associated with improvements in access or health outcomes in which communities.

5 TEN SOLUTIONS

Ten solutions are proposed for rural mental health and well‐being that together would benefit from robust testing and evaluation. They are as follows:

  1. Whole‐of‐community, place‐based approaches are promising: These approaches are established in many countries and place‐based planning is increasingly popular in Australia. Resources and toolkits have been developed by organisations such as the World Health Organisation (WHO). The WHO model has been shown to be successful in an international systematic review but has not yet been trialled in Australia.
  2. New service models tailored to context must be considered: There are numerous innovative models, methods and ideas being tested at a community level that could be scalable. These models need to be tested at a larger scale using appropriate investigative methodologies. Ideally, much of this research would be conceived and conducted by rurally based researchers and partnerships, helping to build rural research capacity. Moreover, these new ways of working (different models) are likely to require new skills in health care providers and new organisational arrangements, which will also require development.
  3. Co‐designed bottom‐up processes should be pursued in collaboration with state and federal partners: Involving place‐based communities in collaborative co‐design can help to build local partnerships, awareness and generate appropriate solutions. These are beginning to be tested using rigorous methodologies. Such approaches can build empowerment, capacity, resilience, social connection and empathy in diverse cultures. Local partnerships are best placed to plan models about how to care for people in crisis locally who could be at serious risk if they cannot access timely assistance.
  4. Holistic and integrated care models need testing: Many rural communities and primary health services have already given‐up on one‐size‐fits‐all centrally imposed models. Many new non‐clinical, community‐based roles are emerging, including service navigators, connectors, peer supporters and outreach workers who can visit isolated‐community members, provide navigation and support. Such workers can provide a cost‐effective source of local prevention, connection and support. However, models engaging lay personnel to complement health and community services would benefit from large‐scale testing.
  5. New better‐aligned funding models are needed: New funding models that reward collaboration provide rural residents and service providers with choices and referral options, enable clinical supervision and professional mentorship need to be developed, modelled and tested.
  6. Whole of community approaches are needed, not pilot studies: These should be co‐designed with rural communities and tested over longer time periods (at least 3‐5 years). Incremental design and improvement is a much better model with a clear recognition that one size will not fit all and that those without personal experience of living in rural communities might not be the best source of wisdom.
  7. Prevention and early intervention must be considered: Local providers and community leaders suggest that prevention is a largely neglected strategy. Building local strategies to address social connection, transport accessibility, mental health literacy and stigma reduction is a fundamental step. Further research summarising and exploring effective and ineffective approaches at the community level would help identify locally relevant strategies.
  8. New rural workforce models are needed: To address specific rural mental health workforce challenges “grow‐your‐own” and “skills escalation” strategies appear promising. These approaches seek to identify existing local practitioners and residents with the potential to become future health and community service workers, peer supporters or volunteer navigators. These strategies require local incentives to encourage staff to work at the top of their scope of practice; “task‐shifting” to non‐clinical or community roles; effective supervision and governance structures. Workers involved could include personnel from the health sector in general, alcohol and other drugs workers, social care, police, social workers and finance/banking workers.
  9. Digital technology contributes now and can do more as part of new systems: Digital and telehealth services continue to play an important role in extending services to rural communities, but they are not a panacea and people might also need immediate face‐to‐face help or specialist advice and care. Understanding the place and value of online, digital and telehealth offerings is a significant research gap. Social media such as Facebook pages that are created and maintained by local practitioner‐community member collaboratives might be useful for people isolated by distance, culture, poverty, negative relationships or lack of connection. The use of online sources of care and support is partly dependent on increased access and expanded bandwidth.
  10. Enhance data collection, monitoring, linkage, analysis and planning: To address the issues of service fragmentation, gaps, duplication and lack of information sharing, there needs to be a substantial investment in better data collection, monitoring and evaluation to enable services to assess outcomes in a timely manner, thereby facilitating responsive service improvement activities.”

The golden hour – unachievable for a chunk of NZ – a problem?

Thursday, October 3rd, 2019 | Rory | No Comments

Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand

Lilley R, Graaf B, Kool B, Davie G, Reid P, Dicker B, Civil I, Ameratunga S & Branas C. (2019). Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study. BMJ Open. 9.

Open Access https://bmjopen.bmj.com/content/9/7/e026026

 

This is a very interesting study that shows that 16% of NZ doesn’t have access to an ‘advanced-level’ hospital within a hour. They have used a novel approach to identifying this population. With regards to trauma care this is a significant finding and something to consider for rural NZ, especially with planning emergency service networks. The average time the ambulance spends responding, travelling to and on the scene (even scoop and run) seems short based on practical experience in areas staffed by volunteer crews that are often 30 minutes to an hour away when called. This will only worsen this ‘inequity’ though

However, for medical events this hour cut-off is a bit more arbitrary. There are few medical events that require treatment within an hour in a major centre that cannot be initiated in rural practice. STEMI can be and are lysed. Airways can be secured. Vasopressors and antibiotics initiated. There are also CT scanners available in a few rural hospitals with Telestroke and stroke fibrinolysis also being available – although stroke care is a mobile beast with the advancement of clot retrieval. Further, many undifferentiated cases may never require transfer to a major centre once proper assessment and investigations are completed in a capable rural centre (either Hospital/GP). If all these patients were transferred immediately, would this be a good use of NZ’s limited resource?

Involving the established rural sector in this care is going to be important to ensure the best use of these resources.

It would be good to use this methodology to look at more patient centred outcomes in the (hopefully near) future.

Abstract

Objective Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services.

Design Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care. Setting Population access to advanced-level hospital care via road and air EMS across New Zealand. Participants New Zealand population usually resident within geographical census meshblocks. Primary and secondary outcome measures The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access.

Results An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access.

Conclusions These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.

 

Edit; fixed link. Thanks to Linda Reynolds for pointing out!

Rural Generalist Workforce

Wednesday, September 25th, 2019 | Rory | No Comments

Rural Generalist Allied Health Workforce – turning lesser into more(er?)

George JE, Larmer PJ, Kayes N. Learning from those who have gone before: strengthening the rural allied health workforce in Aotearoa New Zealand. Rural and Remote Health 2019; 19: 4878. Open access https://doi.org/10.22605/RRH4878

 

“This study sheds light on the current state of NZ’s rural allied health workforce. It highlights opportunities that have been missed for both the advancement of the current and future workforces. Rural practice for Allied Health Professionals (AHP)’s is commonly seen as being lesser; less to offer, less quality, and less access. For those AHP’s who do venture into rural areas, they find that healthcare looks different to urban environments. It has its own unique challenges, having to work across multiple specialist areas with fewer opportunities to put their knowledge into practice. Despite this, specialism and extension of scope is still seen as the pathway for career progression for most AH professions. This can be unattainable in the rural environment due to constrained resources, recruitment challenges, and small numbers requiring speciality input. A potential solution for this issue is the development of a rural generalist role and recognition of this as an advanced scope in its own right.”

Comments with thanks by Sarah Walker – Physiotherapist at Central Otago Health / Dunstan hospital. She is doing a PhD on supporting allied health professionals in rural areas’ where she plans to define the scope of practice, the challenges they face and the attributes and skills needed to reach the full potential of their roles in the rural context.

Abstract:

Context and issues:

The pipeline for the allied health, scientific and technical workforce of Aotearoa New Zealand is under growing pressure, with many health providers finding recruitment and retention increasingly difficult. For health providers in rural settings, the challenges are even greater, with fewer applicants and shorter tenures. As the health needs of rural communities increase, along with expectations of uptake of technologies and the Ministry of Health’s strategy to ensure care is provided closer to home, being able to retain and upskill the diminishing workforce requires new ways of thinking.

Lessons learned:

Understanding the activity that has been undertaken by medical and nursing workforces in New Zealand and abroad, as well as the work of the Australian allied health workforce provides context and opportunities for New Zealand. The challenge is for educators, professional bodies, the Ministry of Health and health providers to develop new ways of thinking about developing a rural workforce for the allied health scientific and technical professions.

 

Sarah

Rural youth in distress

Monday, July 29th, 2019 | Rory | No Comments

Ferguson Isobel, Moor Stephanie, Frampton Chris, Withington Steve (2019) Rural youth in distress? Youth self-harm presentations to a rural hospital over 10 years. Journal of Primary Health Care 11, 109–116.

Open Access
https://doi.org/10.1071/HC19033

A very interesting, but concerning, paper from Ashburton showing significant and rising rates of self-harm in young Ashburtonians/Ashburtonites especially in Māori. We all know that mental health services need bolstering in NZ, especially rurally. Open access paper that is worth a read in full!

Abstract

Introduction: Despite growing awareness of increasing rates of youth suicide and self-harm in New Zealand, there is still little known about self-harm among rural youth.

Aim: This study compared: (1) rates of youth self-harm presentations between a rural emergency department (ED) and nationally available rates; and (2) local and national youth suicide rates over the decade from January 2008 to December 2017.

Methods: Data were requested on all presentations to Ashburton Hospital ED coded for ‘self-harm’ for patients aged 15–24 years. Comparative data were obtained from the coroner, Ministry of Health and the 2013 census. Analyses were conducted of the effects of age, time, repetition, method, ethnicity and contact with mental health services on corresponding suicide rates.

Results: Self-harm rates in Ashburton rose in the post-earthquake period (2013–17). During the peri-earthquake period (2008–12), non-Māori rates of self-harm were higher than for Māori (527 vs 116 per 100 000 youth respectively), reflecting the national trend. In the post-earthquake period, although non-Māori rates of self-harm stayed stable (595 per 100 000), there was a significant increase in Māori rates of self-harm to 1106 per 100 000 (Chi-squared = 14.0, P < 0.001). Youth living within the Ashburton township showed higher rates than youth living more rurally.

Discussion: Youth self-harm behaviours, especially self-poisoning, have increased since the Canterbury earthquakes in the Ashburton rural community. Of most concern was the almost ninefold increase in Māori self-harm presentations in recent years, along with the increasing prevalence among teenagers and females. Possible explanations and further exploratory investigation strategies are discussed.

Chest drain: A guide for for rural docs

Monday, June 24th, 2019 | Rory | 1 Comment

Guest Author: Dr Jonathon Wills 2019

This is a big topic, which I have tried to divide up and cover as broadly as possible. I am only qualified in this by having done a few more than your average rural doctor, due to a previous life as a registrar in cardiothoracics. This hopefully draws together a number of guidelines with a rural focus. If there are any big gaps or contradicting evidence please comment below.

There is a one page summary as a separate document if you want the ‘cheat sheet’ version without the details.

Firstly, here is a summary of my interpretation of the evidence:

NON- TRAUMATIC CONDITIONS:

Pneumothorax

TENSION PNEUMOTHORAX

Obviously needs decompression immediately. This can be via finger thoracostomy or needle decompression. Physician choice as to which method, but the main consideration is timeliness.

There is some evidence that decompression in the midaxillary line, 2nd intercostal space often fails with standard cannulas due to chest wall thickness and that the anterior/midaxillary line, 5th intercostal space may be more reliable.1 Needle decompression needs to be followed by a drain.

SIMPLE PNEUMOTHORAX

Make a distinction between primary and secondary.

Primary Pneumothorax

Normal lung

Evidence here is changing, it seems there has been some local work which is yet to be published, but the results favour more conservative management of primary pneumothorax in most instances. The recommendations here are based on the currently published literature, but watch this space.

Small (ie: less than 2cm at the hilum or 3cm at the apex) can probably be managed conservatively, and are probably safe to monitor out of hospital.2

Large: (more than 2cm at the hilum or 3cm at the apex) may still be able to be managed conservatively in minimally symptomatic patients, but will resolve quicker with aspiration or drainage. Really big ones (ie; complete lung collapse) should have a percutaneous/Seldinger drain.3

This evidence requires a little caution in the rural context where patient might not be able to get back to hospital quickly. I would have a lower threshold for small bore percutaneous/Seldinger drain and making sure no ongoing air leak (ie: the bubbling stops)

There are currently no good studies comparing needle aspiration to small bore saldinger drains (original studies were using large surgical drains and benefit was decreased admission rates plus length of stay.4

Needle aspiration is likely to fail to resolve the pneumothorax with complete lung collapse and tends to fail about ⅓ of the time anyway.5,6 Likewise, if more than 2.5L of air is aspirated there is a high likelihood of ongoing leak, therefore these patients should have a drain.7

BTS guidelines suggest ok to fly after full resolution, rather than a mandatory time-frame. If you work in a part of the world with loads of tourists this may be an indication to drain more frequently.

If there is a need for ongoing transfer, particularly air transport, consideration should be given to drainage prior.

My general philosophy is if I am going to intervene, I do so with a percutaneous drain, mainly because then I don’t have to stand there aspirating, but also because having punctured the pleura, it doesn’t take much to saldinger exchange for a drain.

Secondary Pneumothorax

diseased lung eg asthma, COPD e.t.c.

Due to the compromised underlying lung, these patients are less likely to be suitable for conservative management. Firstly smaller pneumothoraces cause more respiratory compromise due to less physiological reserve.8 Secondly, there is higher risk of ongoing air leak from diseased lung.9

Small secondary pneumothoraces should be observed in hospital and large or symptomatic ones should be drained, needle aspiration has higher failure rates due to ongoing air leak.

Therefore, similar to treating primary spontaneous pneumothorax, if I am going to intervene (which is much more likely in secondary pneumothorax) I tend to put in a percutaneous drain.

Oxygen therapy; very old small human and animal studies show up to four fold increase in resorption with oxygen therapy.10 There is no recent or high quality evidence for this, particularly in light of growing evidence of harm from oxygen.

If your are draining the pneumothorax, short of treating hypoxia there is no point. When pneumothoraces are managed conservatively (and patient not hypoxic) I am not sure of the of the benefit to potential harm ratio.

Pleural effusions

MALIGNANT

Drain properly/dry; 50% will reaccumulate.11 They are likely to need repeat procedure earlier if just aspirated/incompletely drained. Clamp at 1.5L for 2 hours (see note below about re-expansion pulmonary oedema).

Consider early pleurodesis; talc is best agent.12 VATS (video assisted thoracic surgery) pleurodesis is probably the most effective method (95%), though talc slurry is almost as good (90%).13 Lung expansion needs to be confirmed first, as pleurodesis can’t be effective if the pleura aren’t in contact.14 In the rural setting, bedside talc pleurodesis is probably a reasonable therapy given similar success rates to VATS and it could be delivered locally.

Most malignant pleural effusions will reaccumulate. Therefore if survival more than a few months is predicted (LENT score is the only validated tool for this15) more definitive management (ie pleurodesis talc slurry versus VATS procedure) or indwelling pulmonary catheter (particularly if lung trapped because pleurodesis very likely to fail if lung can’t re-expand) should be considered,16 though these procedures are likely to be unavailable at rural hospitals.

Re-expansion pulmonary oedema is a rare but nasty complication of pleural space drainage. Risk factors for re-expansion pulmonary oedema are younger age(20–40), duration of collapse longer than 1 week and volume greater than 3000mL. There is no real evidence for the arbitrary value of 1.5L, re-expansion pulmonary oedema has been reported at much lower volumes. In fact most of these risk factors seem to be very old and week evidence and the most recent case series suggests it doesn’t matter, (though they did use manometry to ensure no greater than –20cm intrapleural pressure). In this case fluid was removed manually via syringe- not by free drainage.17

PARAPNEUMONIC EFFUSIONS:

Uncomplicated

ie: either too small to sample, or a free-flowing small effusion has a neutrophilic exudate (an elevated protein level >0.5 percent of serum and/or a lactate dehydrogenase (LDH) level >0.6 that in the serum), a normal pH, a normal glucose level, and does not contain micro-organisms

Probably OK to leave alone and will resolve with appropriate treatment for pneumonia. Parapneumonic effusions that don’t meet above criteria are considered complicated and should be drained percutaneously.18

Loculated effusions

Intra-pleural fibrinolysis can help based on a few small RCTs and is probably ok to do rurally as relatively low complication rates.19,20

Empyema

Needs to be drained, small bore probably ok.21 Intrapleural fibrinolysis as above can reduce the need for surgery

Ultrasound guidance is good for drains is good. (Bedside of course); (0% vs 33% failure rate; 3% vs 18% pneumothorax).22,23

TRAUMA

Pneumothorax

CLOSED PNEUMOTHORAX

Should probably be drained based on current practise. There is very little data unless they are small.24

ATLS convention says all traumatic pneumothoraces should be drained.25

Occult traumatic pneumothoraces (those seen on CT but not plain X-ray can probably be managed conservatively (90% no significant deterioration), even those on positive pressure ventilation.26,27 (This is retrospective observational data and those treated conservatively had smaller pneumothoraces than those who were drained.) Those with concurrent haemo-pneumothorax were more likely to fail conservative management.

I can’t find any evidence about ‘occult pneumothoraces’ when diagnosed by ultrasound rather than CT- but maybe similar to ones on CT?

There is growing evidence towards smaller drains (open insertion) and percutaneous drains are probably OK based on very small trials.28,29

In the setting of chest tube placement for traumatic pneumothorax; antibiotics should be given to cover staph and strep (less pneumonia and empyema).30

OPEN PNEUMOTHORAX

Initial management:

Three sided dressing appear out- they mostly don’t work. Recommendations are to occlude wound with a vented dressing if available, if not simply seal the wound with an occlusive dressing and monitor closely for signs of tension pneumothorax.31

I am a little sceptical here, occlusive dressings seem unnecessarily risky. Did someone on the committee have shares in a specialised vented dressing?

Definitive management:

Place chest tube through a clean site, close wound (simple dressing is fine initially, or formal closure provided that don’t meet indications for the formal operative thoracotomy)-

I can’t find any good evidence for this other than various brief statements in various trauma guidelines.

Haemothorax

Drain it unless very small- retained blood in the pleural space is a problem; complication include empyema (up to 33%) or fibrosis impairing lung function.32

However, there is some suggestion a more conservative approach is coming here too!33 However about ⅓ of those observed initially did require a drain. Four independent predictors of failed observation were identified: older age, fewer ventilation-free days, large hemothorax, concurrent pneumothorax.

Small drains are OK,34 Seldinger ones probably are too.35 It seems blood will come out fine through any sized tube, but clot won’t drain regardless of tube size.

INDICATIONS FOR SURGERY

therefore transfer to a cardiothoracic service if you haven’t already…

There is some retrospective evidence that a combined total of more than 1500 mL blood from a chest tube has higher mortality and this value can be used regardless of rate of accumulation.36 Beyond this most guidelines state: greater than 1500 mL total or more than 200mL/hr for 2–4 hours.

Haemo-pneumothorax

These should usually be drained as per haemothorax. Also, as above, pneumothoraces are more likely to require drainage if associated blood.

A rant…

Having covered the covered the evidence, I cannot finish without a personal rant.…

Open tube thoracostomy (ie: surgical drain) is a very different procedure to percutaneous techniques (eg: Saldinger) and you need to have different considerations prior to procedure. I commonly see ideal locations for the two confused.

An open tube thoracostomy is a surgical procedure that requires safe access to the pleura.

Considerations for location of this procedure involves establishing safe passage through minimal tissue to the pleural space. Traditionally this is the ‘triangle of safety’ around the 4/5th intercostal space in the anterior/midaxillary line (though the 2nd intercostal space midclavicular line can also be used). Because the pleural space is entered by blunt dissection and then confirmed by palpation of the back of the ribs it does not matter if the lung is adjacent to the pleura, it will be safely pushed away by blunt objects as you enter the pleura. Therefore the location of an open tube thoracostomy is determined by safe access to the pleural space, NOT maximal point of pneumothorax or blood/fluid.

In contrary, a percutaneous technique involves using a sharp object to enter the pleural space. (Ultrasound guided of course) To enter the pleural space safely with a sharp object you need space between needle tip and lung. Therefore the best location for this procedure depends mainly on biggest space between visceral and parietal pleura. (though safe passage through the chest wall needs to also be considered, given it is a minimally invasive technique this is less important) Ultrasound guidance means in the setting of pleural fluid you can determine the best location based on a large space between pleural layers. (This will depend on patient position). In the setting of pneumothorax, ultrasound can only determine the pleura are not opposed, rather than the distance between them. Regardless, the same principle applies, you should be placing a saldinger drain only where there is a safe gap between parietal pleura and lung.

Finally when you are securing drains, please don’t spiral the tie up around it, the shortest distance around a cylinder is the circumference, not a spiral- a spiralled tie will slide down and come loose, it may look pretty but its not effective!


Jono is a rural doctor based in Wanaka. He works at Dunstan Hospital and Wanaka Medical Centre. LOFP is extremely grateful for the time Jono put into this review! If anyone else has a post/topic they would like to cover then this ‘donation’ will be received with a great deal of thanks.

Jono snowed under…


  1. Laan, D. V., Vu, T. D. N., Thiels, C. A., et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. https://doi.org/10.1016/j.injury.2015.11.045
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