http://www.amicusvisualsolutions.com/obrasky/05001_02X.jpg

picture :)

Indications
Emergency
Pneumothorax
-In all patients on mechanical ventilation
-When pneumothorax is large
-In a clinically unstable patient
-For tension pneumothorax after needle decompression
-When pneumothorax is recurrent or persistent
-When pneumothorax is secondary to chest trauma
-When pneumothorax is iatrogenic, if large and clinically significant
Hemopneumothorax
Esophageal rupture with gastric leak into pleural space

Non emergency
Malignant pleural effusion
Treatment with sclerosing agents or pleurodesis
Recurrent pleural effusion
Parapneumonic effusion or empyema
Chylothorax
Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)

Contraindications
- when a lung is completely adherent to the chest wall throughout the hemithorax
- a risk of bleeding in patients taking anticoagulant medication or in patients with a predisposition to bleeding or abnormal clotting profiles


Procedure
Preperation
-Patient in supine position
-Maximally abduct the ipsilateral arm or place behind head.
-The area for incision is 4th to 5th intercostal space in the anterior axillary line at the horizontal level of the nipple.
-Triangle of safety: Ant border of lat dorsi, lat border of pectoralis major muscle, the apex just below the axilla and a line above the horizontal level of the nipple.
-Ensure sterile field is created.
-Use LA for deeper subcut tissue & intercostal muscles and periosteal surface & parietal pleura. (lidocaine)

Incision
-Incise 1.5-2cm parallel to rib
-Cut through subcut layers & intercostal muscles
-Path should transverse diagonally up toward the next superior intercostal space. Push thru the paretal pleura, you may also digitally penetrate the pleura to avoid puncturing lung tissue, using your index finger to explore and palpate within the pleural layer & ensure the lung falls away from the pleura. If it does not, this may show e presence of an adhension.

Tube Insertion
-Once the distal tip of the tube has passed through the incision, unclamp the Kelly
clamps or forceps & advance the tube.
-Aim the tube apically for evacuation of a pneumothorax and basally for evacuation of any fluid.

Securing the Tube
-Sutures should be used on both sides of the incision to close the ends.
-Use the loose ends of the sutures to wrap around the tube and tie them off
-Tape the tube to the side of the patient & wrap gauze dressing & multiple pressure dressings around the tube.
[Purse-string sutures are not recommended owing to poor cosmetic results and increased risk of skin necrosis; the seal they provide does not prevent air leaks.]
-Connect the distal end of the chest tube to a sterile pleural drainage system,unclamp
the distal end; Do not reclamp the chest tube, once released, may lead to the redevelopment of a pneumothorax and may create a tension pneumothorax.

Chest Radiograph Confirmation
-AP chest radiograph to confirm placement,If the proximal drainage hole is outside the pleural space,drainage may be ineffective and an air leak may result. In this circumstance, remove & a new chest tube inserted.

Complications
-bleeding and hemothorax due to intercostal artery perforation
-perforation of visceral organs (lung, heart, diaphragm, or intraabdominal organs)
-perforation of major vascular structures such as the aorta or subclavian vessels
-intercostal neuralgia due to trauma of neurovascular bundles,
-subcutaneous emphysema
-reexpansion pulmonary edema
-infection
-pneumonia
-empyema.

I shall not talk about chest-tube removals.. haha I will bore you guys to death:)

Source: NEJM

liability / responsibility and duty/standard of care

Plaintiff must establish, on the balance of probabilities, that:
• The defendant (doctor/health care provider) owed a duty of care
o What is a duty of care
 In tort law, a duty of care is a legal obligation imposed on an individual requiring that they adhere to a reasonable standard of care while performing any acts that could foreseeably harm others
o What makes the doctor owe a duty of care (VIC)
 Where a doctor agrees to treat a patient or commences to treat a patient.
 Occurs both where a patient expressively or implicatively agrees to be treated and to patients who are unable to agree to treatment (unconscious, mental illness – not of sound mind)
o Did Josh owe a duty of care?
• The defendant failed to meet the standard of reasonable care
o Was there a breach of duty of care and why
 The standard of reasonable skill and care required is that of the ordinary skilled person exercising and professing to have that special skill.
 That standard is peer-assessed
 For junior doctors: An inexperienced junior doctor will be judged according to the standard of a reasonably competent medical practitioner in a particular are of medical expertise. Junior doctors are rarely assigned to complex procedures – however if a junior doctor is found in a situation which is beyond his competence, the fault lies not so much in not having the skills, which he does not possess, but in undertaking the task at all.
 In such situations – obligation to consult more experienced physicians – judged by their standard of care.
 “If a doctor lacks a minimum competence to carry out a particular procedure but it is proper for him to be present then whatever he does must be done under the supervision of the experienced doctor. The negligence if any will now be that of the experienced doctor for failure to supervise.”
o Did Josh fail to meet the duty of care?
• The breach caused the plaintiff’s injuries (causation-covered in rushmis section)
o Did Josh’s actions cause injury
• The injury/loss was reasonably foreseeable
o What makes a loss foreseeable
 Insignificant risks include, but are not limited to, risks that are far-fetched or fanciful
 Inherent risks are defined as risks that cannot be avoided by the exercise of reasonable care. Liability for injuries occasioned as a result of the materialisation of an inherent risk is specifically excluded.
 Severity of injury/loss vs likelihood of injury/loss
o Was the injury a foreseeable risk?

Prevention

Wonderful task...

Well, not really researchable, so my response was to sit in the library in silence for 45 mins and brainstorm. Here goes:

For the individual, Josh in this case, there is little chance of him actually repeating the error. Presumably, after the event he would both research the relevent anatomy and procedural details, and would also probably ask for specific instruction and demonstration from a senior doctor.

In terms of the Hospital, or the overall system, they could help prevent such errors in the future by:
-Reinforcing emergency protocol and hierarchy affairs (eg what can be expected of new doctors)
-Hospital training on emergency management and procedures
-systems design of the ED - locations and proximity of staff, triage grading system
-Procedural instructions made available with the instrument (chest tube)
-Upgrading/renewing reporting and reviewing systems
-Clinical schooling upon induction to the hospital, to assure an appropriate level of knowledge.

sources: none really, though there's an interesting text called "To Err is Human"

Anatomy

A very broad topic, so I thought it would be best to concentrate on what is most relevant to this case:

The Original Penetrative Wound
The patient was stabbed with a kitchen knife, causing a penetrative wound 15x1.5cm deep, entering in the right chest, in the mid-clavicular line at the level of the right nipple.
As it was entering, the knife would have passed through many layers and structures before entering the thoracic cage, including:
 Skin (dermis)
 Mammary tissue + associated glands
 Subcutaneous tissue
 Pectoral fascia
 Pectoralis major
 Pectoralis minor
The knife is likely to then have passed through an intercostal space, likely the fourth or fifth, damaging the following structures
 The external, inner and innermost intercostal muscles
 The neurovascular bundle, consisting of a vein, an artery and a nerve which runs between the inner and innermost intercostal muscles.
From here, the knife would have pierced the parietal, then the visceral pleural membranes before puncturing the lung.

The Drainage Tube
A correctly placed drainage tube is inserted in an intercostal space (usually the 2nd-6th) “just above the rib below” in order to avoid the neurovascular bundle at the top of the space. Its purpose is to drain fluid or air from the pleural cavity, and hence the chest tube is inserted into this space. The layers the chest tube is passed through before reaching the pleural cavity are:
 Skin (dermis)
 Subcutaneous tissue
 Fascia
 Muscles of the upper limb eg. Pectoralis major and minor/Serratus anterior (which ones depend on the where the tube is being inserted)
 The external, inner and innermost intercostal muscles
 The parietal pleural membrane

In our case however, the drainage tube was placed at an intercostal space too low, so that instead of being inserted into the pleural cavity, it was put into the liver, at the level of about the 8th intercostal space. The layers the chest tube passed through in this case are likely to be:
 Skin (dermis)
 Subcutaneous tissue
 Fascia
 Latissimus dorsi
 The external, inner and innermost intercostal muscles
 The diaphragm
 The liver

References: Moore's, Last's, Netter's
By Steph

Oops... forgot references!

http://www.acem.org.au/home.aspx?docId=1
http://en.wikipedia.org/wiki/Triage
http://www.answerbag.com/q_view/4880

Hierarchy in the Hospital

In the hospital -

PGY1
PGY2
INTERN
RESIDENT
REGISTRAR 1
REGISTRAR 2
REGISTRAR 3
(Years as a Registrar are dependent on the Training Program undertaken)
CONSULTANT

In the Emergency Department
1. All patients are assessed on arrival, usually by a nurse
2. Urgency of each patients' condition is assessed
3. All patients are assigned a 'triage' category
Then
- Category 1 Patients are treated immediately
- Category 2-5 Patients are transferred to a waiting area

Triage

In Australia the Australasian Triage Scale (ATS) is used in Hospital emergency department in an attempt to have reproducibility in Emergency Departments across Australia.

When arriving in the emergency department a patient presents to the Triage Nurse who then places them into one of five different categories:

See handout


All patients should be sorted using this model, including pediatrics.

References:
http://www.medeserv.com.au/acem/open/documents/triage.htm
http://www.medeserv.com.au/acem/open/documents/triageguide.htm

Triage

Shock

When SHOCK occurs, generally there is an inadequate delivery of nutrients to critical tissues and organs, and also an inadequate removal of cellular waste products from the tissues. The cause of this inadequacy can be of cardio- / hypovolemic- / neurogenic- / anaphylactic-/ septic origin, however ultimately, lead to the deterioration of different body parts.

In the case of cell hypoxia, the non-progressive phase of shock then kicks in, in which our body’s negative feedback mechanisms attempt to return normal cardiac output and arterial pressure i.e. to recover from shock, by, namely, baroreceptors, renin-angiotensin system etc. However, when failing to recover from shock, shock proceeds to the progressive phase. The cause of shock and its resulting effects on, say, low systemic filling pressure, or reduced venous return etc., become a vicious circle that eventually leads to an irreversible deterioration of circulation and, to death.

Cadiogenic shock
i.e. body suffers from lack of nutrition and deteriorates due to inadequate cardiac pumping, in which, 1) often occurs after acute heart attacks or prolonged periods of slow progressive cardiac deterioration; 2) caused by a decreased venous return
- problem can be compounded by a low arterial pressure e.g. in circulatory shock, which reduces the coronary blood supply even more
- the condition thus becomes a vicious circle i.e. shock causes more shock
∴elevate arterial pressure!!! By infusion of whole blood / plasma, or blood-pressure raising drug

Hypovolemic shock
i.e. diminished blood volume caused by, most commonly, haemorrhage, which then decreases the filling pressure of the circulation and, as a consequence, decreases venous return; as the result, cardiac output falls, and shock comes after.

Neurogenic shock
When there is massive dilation of veins, mean systemic filling pressure decreases; thus, filling the circulatory system adequately had become incapable even with a normal amount of blood. Venous pooling of blood reduces cardiac output, therefore limits the gaseous and nutrition exchange around the body.

Anaphylactic shock
In anaphylaxis, basophils and mast cells release histamine, which causes dilation of veins and arterioles, as well as an increased permeability in capillaries. The effect of these is a great reduction in venous return, and shock.

Septic shock
A septic shock occurs when a blood-borne bacterial infection widely spread around the body, causing extensive damage. Signs of circulatory collapse often include marked vasodilation in patients with septic shock, while high fever from the infection is a possible cause. As the infection becomes more severe, the circulatory system deteriorates at the same time, and shock becomes more progressive.

Reference: Guyton

Shock

Shock – acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in generalized cellular hypoxia.

Hypovolaemic – loss of circulatory volume (eg. haemorrhage, burns)

Cardiogenic – failure of the heart to act as an effective pump (eg. ischaemic heart disease)

Obstructive – mechanical impediments to forward flow

Obstruction to outflow (eg. pulmonary embolus)

Restricted cardiac filling (eg. cardiac tamponade, tension pneumothorax)

Distributive – abnormalities of the peripheral circulation (eg. sepsis, anaphylaxis)

Stages of shock

1. Non-progressive phase

Baroreceptor reflex, adrenaline and noradrenaline release (increased TPR, HR, CO).

Renin-angiotensin activation, release of vasopressin from pituitary (increased blood volume).

Net effect is to increase blood pressure back to normal.

2. Progressive phase

Generalised tissue hypoxia leads to cells switching to anaerobic respiration and eventually lactic acidosis occurs. The lactic acid causes vasodilation and blood starts to pool in microcirculation and more blood fluids will leak into surrounding tissue.

3. Irreversible phase

Generalised tissue injury leads to irreversible organ failure. Death eventuates.

References: Kumar and Clark Clinical Medicine, Robbins Basic Pathology

Presentation of penetrative trauma

Penetrative trauma – presentation and management

Definition of penetrative chest trauma:Penetrative chest trauma is when a an object (usually sharp/bullet) enters the chest causing a small or large entry hole. The object may hit other contents in the chest, affecting the patient’s safety.

Anatomy:
Among the structures that may be damaged are:
1. Thoracic cage (ribs, stenum, manubrium)
2. Mediastinum and the contents(superior, anterior, middle, posterior)
3. Diaphragm

Presentation:
Patients who came in the emergency department with a penetrative chest trauma often seen presented with these conditions:
1. Decreased consciousness
2. Absent/tachy/brady pulse rate
3. Hyper/hypotension BP
4. Tachy/bradypnoea
5. Shortness of breath
6. The chest is not rising normally during inhalation,
7. Blue lips, tongue due to lack of oxygen in blood (cyanosis)

They can be in 3 different presentation: extremis -> unstable (profound shock) -> stable

Among the injury caused by penetrating trauma to the chest:
1. Open pneumothorax: a hole in the chest allows air to enter the pleural space and prevents development of negative intrapleural pressure.
2. Tension pneumothorax: air enter pleural space but cannot leave and trapped. Eventually, the affected lung become compressed and pushed aside along with other structures.
3. Hemothorax: blood accumulated in pleural space due to injury to blood vessels. Leads to tension pneumothorax.
4. Pericardial tamponade: rapid accumulation of blood in the pericardial space which usually filled with small amount of fluid for heart movement.

Management of penetrative chest trauma in emergency department:
1. Investigation: Chest X-ray (all), transesophageal echocardiograms, CT scans and angiography required in complex cases (stable ptx).
2. Pre-hospital management: If the ptx has tension pneumothorax, apply needle thorascopy and administer oxygen mask.
3. Emergency room management:
a. Obtain the x-ray prior to chest tube insertion, except in the case of tension pneumothorax or the ptx is rapidly dying.
b. Estimate the degree of hemothorax/pneumothorax.
c. Identify if there’s any fractured ribs that may indicate arterial bleeding.

4. Emergency room thoracotomy:
a. For ptx with witnessed signs of life. (ptx with cardiac arrest, presence of hemothorax/pneumothorax)
b. Apply cross-clamping to the hilum to control haemorrhaging from lung and prevent further air emboli.

5. Management in the operating room:
a. Indicators for operation due to penetrating chest injuries:
i. Aorta, subclavian or carotid artery injuries.
ii. Hilar injuries.
iii. Bronchus, trachea and oesophagus injuries.
iv. >250ml blood loss/hour for >2 hours.
v. Massive clotting hemothorax.
b. Procedures in operating room:
i. Thoracotomy incision: Anterolateral for unstable ptx on the injury side. Posterolateral for oesophageal(right) and aortic(left) injuries.
ii. Pulmonary tractotomy for lung injuries in unstable ptx.
iii. Thoracoscopy to examine mediastinum, remove blood clot and evaluate diaphragm in stable ptx.

LAW

It has been recognised that domestic violence is a major health problem
in western societies, including Australia, and bodies such as the Australian
Medical Association (1989) and the Public Health Association of Australia
(1990) have called for the development and evaluation of protocols to
increase identification and enhance the management of domestic violence
victims. Indeed, one of the recommendations of the National Committee on
Violence in Australia (1990) was that medical education, whether
undergraduate, postgraduate or continuing, should include components
dealing with all aspects of violence. Studies have shown that victims of
domestic violence consult doctors more often than they consult police,
social workers or any other group of helping professionals (Dobash &
Dobash 1979; Dobash et al. 1985).


Disclosure of medical error in Australia
Adverse events happen

Routine disclosure of adverse events is inevitable

Implementing disclosure is difficult – a mediation model may be the way
forward

Adverse events happen

Medical treatment is inherently risky

Adverse event: “an incident in which unintended harm resulted to a person
receiving health care.” (ACSQHC Open Disclosure Standard, 2003)

Occur in approx 10.6% of admissions (QAHCS 1995) – comparable with
overseas findings

Harvard study (USA): 18,000 people die every day partly as result of
iatrogenic injury (harm during health care)

Equivalent to 3 jumbo jets crashing every 2/3 days

50-80% of errors may be preventable

Not all errors involve negligence

Errors mostly due to system error

Routine disclosure of adverse events is inevitable

Ethical obligations

Legal duties

Open Disclosure Standard

Open Disclosure Standard

Open disclosure: open communication when things go wrong in health care

Elements:

Apology/expression of regret

Factual explanation of what happened

Explanation of potential consequences

Explanation of what is being done to manage the event and prevent its
recurrence

Implementing disclosure is difficult

Legal barriers: adequacy of legislative protection for apologies, fear of
increased litigation

Physician barriers: guilt, embarrassment, fear of reaction from peers, fear of
punitive sanctions, communication difficulties

Open disclosure
Open Disclosure involves clinicians in signalling to the patient and/or the
patient’s family that an adverse event has occurred.

“openness and honesty can help prevent events form becoming formal complaints and litigation claims” because “[b]eing open when things go wrong is clearly
fundamental to the partnership between patients and those who provide
their care” (National Patient Safety Agency, 2005). Open Disclosure policy
frames these moral-ethical principles within a legal liability discourse
however that sets limits on precisely how disclosure and its attendant
apology are articulated and enacted in situ.

How staff enact the openness that is advocated in Open Disclosure policy
is thus contingent on the degree of legal protection given to disclosures and
apologies. The challenge here is that staff needs to come to terms with the
uneven and often shifting legal landscapes that impact on them and their
work. In Australia, for example, partial apologies (‘We are sorry this
happened’) are nationally advocated, even though apology legislation in
New South Wales and the Australian Capital Territory (ACT) is such as to
prevent full apologies (‘We are sorry we made a mistake’) from being
admissible in court. Another challenge that lies at the heart of Open
Disclosure is the requirement that clinicians disclose adverse event
information to people who are physically injured and likely to be
psychologically affected by those adverse events.


Waiver of confidentiality with regards to disclosure to the police when it comes to trauma ( stab wounds)

A substantial risk of serious avoidable harm to third persons will nearly always justify a breach of secrecy.There are provisions in various state and territory acts which will indemnify doctors against patients taking civil actions for certain disclosures. where summary offences are concerned, the attending doctor is under no duty to disclose information to the police. a somewhat diferent problem may arise when doctors are made aware from a patient that a serious criminal offence has been commited.

Patient may disclose that their condition has arisen as a result of the latter, or police may seek information from the doctor concerning a patient whose condition they believe may have resulted from a criminal attack. If the consent of the patient to diclose such information is not obtainable, doctors other than in queensland, must use their own judgement as to what course to take.

Extra- in queensland, there is an obligation of the attending doctor in situation as :
when called to treat any wound from a cutting instrument or other weapon( not being a firearm) which he is not satisfied was accidentally incurred, or to treat any wound from a bullet, fails to advice the member of the police force incharge of the nearest police station by the most speedy method of correspondence, whether the same be by telephone, telegraph or letter.

How to break bad news
First, get a chair. Everyone must have a chair. When it comes to bad news, you must assert authority you didn’t know you had. Insist on having a private room. Move people out, clear a space. You can be a dictator. You get what you need by polite, quiet insistence.
Never give bad news standing up. Never, ever, ever give bad news in a hallway. As you’re getting the room, and the chair, people will become alarmed and ask you what has happened. You wait, saying you’d like to talk about it in private, please. You seat everyone. You take a deep breath, then you say it. And then, most importantly, you say you’re sorry.
You must keep in mind that only the first few words will be heard. After that, the mind shuts out the rest. Sometimes you hold a hand or pat a shoulder. Most of all, you wait. You wait some more. Often, like a trickle before the flood, there will be tears, then sobbing. Your job is to get tissues (if you have not thought to do so beforehand). If there is no crying, you let the silence stretch, no matter what else you have to do. If you have sadly forgotten to turn off your pager beforehand, you silence it if it rings. You can take these few moments for something this important.
Eventually there will be questions. You answer them with the facts you have, leaving out all interpretation, excuses, religion, or philosophizing.

references
http://www.nadrac.gov.au/
http://www.aic.gov.au/publications/aust-violence-2/roberts.pdf
http://books.google.com.au/books?id=NPi8YUWvKGEC&pg=PA44&lpg=PA44&dq=law+%2B+doctors+%2B+disclosure+%2B+patients+%2B+police&source=bl&ots=ZPDLyCAE3s&sig=WoNx3Cix9YEGYni0Xl3UQuskFF4&hl=en&ei=v2TLSYD6J4aMkAXwqKDeCQ&sa=X&oi=book_result&resnum=9&ct=result#PPA45,M1
http://www.docgurley.com/2008/01/19/how-to-break-bad-news/

Negligence (criminal and civil) and malpractise

Negligence action (tort of negligence) - Civil negligence action for damages

Negligence is established on the basis of:
· Precedents (previously decided cases)
· Admissible and available evidence
o E.g. Testimony of expert witnesses
· The court relies on an objective test of what a reasonable doctor should have done/not have done
o Peer professional opinion has a role

Patients must satisfy the statutory threshold levels for negligence claims:
· Apply to claims for damages for pain and suffering
· Don’t apply to economic losses à ensures trivial claims don’t go to court
· Impairment level must be assessed by an approved medical practitioner:
o Significant physical injury threshold – 5%
o Significant psychiatric injury threshold – 10%

Plaintiff must establish, on the balance of probabilities, that:
· The defendant (doctor/health care provider) owed a duty of care
· The defendant failed to meet the standard of reasonable care
· The breach caused the plaintiff’s injuries
· The injury/loss was reasonably forseeable

Causation – defendant’s acts/omissions must have caused the injury:
· Negligence was a necessary condition of the occurrence of the harm (factual causation)
· It is appropriate for the scope of the negligent person’s liability to extend to the harm which has been caused (scope of liability)

This is the less serious category of negligence:
· Lower level of negligent conduct
· Is a matter of compensation

Involuntary manslaughter - Criminal

· Person is killed due to grossly negligent act/omission
· An act is deemed dangerous by the reasonable man test
o Objective test – what a reasonable person would do in the same situation
· The prosecution must prove beyond a reasonable doubt, that the accused was aware of the unjustifiable risks of their behaviour, and yet he/she continued to pursue this behaviour

Negligent manslaughter - Criminal prosecution for manslaughter

The plaintiff must prove beyond a reasonable doubt that:
· The accused owed a duty of care to his/her victim
· His/her conduct involved a significant departure from the standard of reasonable care expected
· There was a high risk that death might follow

This is the more serious category of negligence:
· There is such disregard for the life and safety of others that it amounts to a crime against the State

Professional misconduct

· Must demonstrate a degree of negligence that lies between the civil and criminal standards

Professional misconduct includes:
· Conduct of a health practitioner in their practise that is of a lesser standard than the public and the practitioner’s peers are entitled to receive from a reasonable competent health practitioner of that kind
· Professional performance that is of a lesser standard that that which the registered health practitioner’s peers may reasonably expect from them
· Providing a person with health services that are unnecessary, excessive or no reasonably required for that individual’s well-being
· Attempting to influence or influencing the provision of health services in a way that may compromise patient care
· Failure to act as a health practitioner when required to do so under and Act or regulation
· A finding of guilt of:
o An offence where the practitioner’s suitability to continue to practise is likely to be affected by a finding of guilt, or where it is not in the public interest to allow the health practitioner to continue to practise due to the finding of guilt
o An offence under this, or any other, Act or regulations
· Contravention (an act which violates a law, treaty or agreement made by the individual) or failure to comply with a condition imposed on the registration of the health practitioner by or under an Act
· The breach of an agreement made under an Act between a health practitioner and the board that registered the practitioner

Sources: Law notes from last year, MPBV website
-Rushmi

Tasks for the Week

Tasks for the Week

Catheter Insertion- Jemma
Hospital Hierarchy- Georgia
Legal + Ethical implications....disclosure to authorities (Jac) and with reagrds to interns (Rushmi/Nathan)
Grief Counselling (ambu)
Shock...Dilys/Lionel
Protocol/Presentation of penetrative trauma...Hasif
Triage...Sarah
Anatomy...Steph
Structures endangered in penetrative trauma...Kylie
Learning from past incidents...Sam