On Chest Tubes and ATLS


I studied up for a test

That involved a tube in the chest

For the old and the young

When collapsed is the lung

That treatment, life-saving, is best. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I drove south to Kansas City for the Advanced Trauma Life Support (ATLS) course.

In medical school, I saw exactly one chest tube insertion, involving the “best chest surgeon in town” (in retrospect, either bipolar or alcoholic but more likely both).  I watched the surgeon make repeated jabs with a scalpel into the chest of an unanaesthetized late adolescent man who had come to philosophical terms with his upcoming death from cancer and just wanted to die comfortably. I observed the screaming and the torture for as long as I could.  When my vision contracted down to a tunnel, I knew I would faint, and rather than do so at the patient’s bedside, I forced one foot in front of another down the hall to the dictation desk behind the nurses’ station, laid down, and fainted.

The experience put me off chest tubes, but chest tubes can make the difference between life and death when a lung collapses (pneumothorax) or blood pools inside the chest on outside the lung (hemothorax).

The first time I did the ATLS course we used live, anesthetized dogs and cats to practice endotracheal tubes, venous cut downs, and chest tubes.  It bothered me then and it bothers me now that the animals did not survive our education, but the experience of the dying 18-year-old bothers me more.

I got out of the Emergency Room.  My certification lapsed, decades passed and the century turned before I needed that credential again, when my work in remote locations brought me to ER coverage.  In December of 2010 I took the ATLS again.  We used manikins for practice, not living animals.  Venous cut downs had almost disappeared.

I do not regret never having to use those skills.

Now that I stalk the locum tenens trail again, some facilities want the credential, and I discovered, to my chagrin, that mine lapsed a year ago.

Venous cut downs, the last ditch to get IV access, have disappeared in favor of a technique that bores into a long bone, called interosseous.  Endotracheal tubes continue.  The scopes still use incandescent light bulbs, having failed to progress to halogen, they may skip directly to LED but will more likely be replaced by the video Glidescope by the time I recertify next, in 4 years.

The chest tube practice manikins continue to improve, providing a closer simulation to a live human than a cat or dog ever could.

I hope I never have to use my skills.

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