Pneumothorax

Author Question: Details for Chest Tube Placement

/ Jordyn Redwood / Leave a comment

Rachael Asks:

I’m sure you get questions on this all the time, but I was wondering what insight you can provide on traumatic wounds. My project is science fiction and the characters in question have enhanced healing and a sped up metabolism which I’ve just been using as my cure-all, smooth-over for any inaccuracies thus far. But then I found your blog- which has been incredibly fascinating and entertaining.

The first question I had which led me here was in general for a gunshot wound to the chest though not involving the heart. Namely, the various potential complications, the meds, supplies, or procedures that may be employed, and the sorts of phrases and terminology and reactions that may be overheard from the staff working on the patient. I’ve read on the risks of things like a sucking chest wound and consequential lung collapse, punctured lung, of course blood loss, but I still am at a loss for particularly the things the medical staff on hand would be saying or doing. (Bonus points if you have any tips for the internal monologue for the victim besides “ow.”)

Jordyn Says:

Hi Racheal! Thanks for sending me our question.

Your question is hard to answer. You don’t give specifics of the injury though it looks like you’re leaning toward a collapsed lung. There are a couple of ways you can research the feel of an emergency and that is by watching reality based (non scripted) shows that center on emergency medicine or look for teaching videos (or live videos where they capture the procedure on a real patient on You Tube).

For instance, a patient with a collapsed lung will likely need a chest tube placement. You can search You Tube for “placement of a chest tube” and see what comes up. The below video is pretty good as it gives lots of technical detail on what the physician is doing, seeing, feeling, and even what medicines might be prescribed for the patient. However, it does lack a lot of language of what would be said to the patient during the procedure.

The next video shows more patient interaction and what might be said. Between these two videos you could probably extrapolate together a scene. I will say that typically patients are connected to a larger suction device, but what the below physician is connecting to looks to be a more portable device so the patient can be up and walking. Also, a patient with a tension pneumothorax who is crashing may not receive local anesthesia and may even be unconscious.

Your best option, once the scene is written, is have a medical person who actively is practicing in the field review it. If your scene is written from the POV of the doctor placing the tube, it would need to be more technical versus if you’re writing it from the POV of the patient. You can also search Google for patient experiences of having a chest tube placed to get a feel for the inner dialogue you’re looking for.

Hope this helps and good luck with your story!

Author Question: Law Enforcement Shooting with Vest in Place

/ Jordyn Redwood / Leave a comment

Carol Asks:

I have a cop who is involved in a shooting. She’s wearing a vest and is hit outside the vest’s protective area. I need her hospitalized long enough that the shooter (who she killed— they shot simultaneously, more or less) to have been claimed post autopsy. I can’t have her debilitated for months— just a week or two. Where would I shoot her? Hip? Leg seems hard to hit and shoulder does too. I don’t want her disabled, nor do I want a months long rehab.

Jordyn Says:

What I would recommend is a shot coming through the side, under the armpit, causing the lung to collapse. I would pick the right side over the left— there’s just a lot more vasculature on the left that could prove deadly/problematic. If her right arm was raised and she was say . . . turning into the shot . . .  it could leave her vulnerable.

She would have difficulty breathing. How difficult would depend on how quickly the pneumothorax (air moving into the chest and deflating the lung) expanded. She would be transported to the ER via ambulance and receive an IV, oxygen, and vital sign monitoring.

A chest tube would be placed, likely after a quick chest film, unless she is in significant distress to re-expand the lung. If in significant respiratory distress or cardiovascular compromise then she would get a rapid needle decompression to buy some time or some facilities will go straight to chest tube placement. For a “simple” pneumothorax she would be admitted into the hospital (regular floor— not ICU) and observed.

Generally, depending on the size of the pneumothroax, it’s a few days to get the lung to re-expand, a day or two with the tube to “water seal” to make sure it stays up without suction, and then the tube would be removed. Maybe one or two more days after that to make sure all was well.

If she’s young and healthy she should recuperate pretty quickly, but would still be winded, perhaps easily fatigued for another week or two.

Hope this fits your time frame.

Author Question: Gunshot Wound to the Chest

/ Jordyn Redwood / Leave a comment

Virginia Asks:

I’m putting the final touches on a romantic suspense novel in which my hero is shot. The most important part of this is that he has to continue to function until he saves the day, then falls and has to be treated. The wound cannot be bad enough that he can’t pass the physical and qualify to become an FBI agent within a few weeks.

My fit male character (34 years old) is in a shootout. He’s shot with a 9mm handgun but the bullet ricochets, grazes his chest, and fractures a rib. He doesn’t notice initially. He begins to feel some pain after about five minutes. Then feels woozy and has a head rush. I want him to fall after the action is over, but be able to talk a little with some struggling.

He’s far from a hospital when he’s shot, but a military medic is there with his kit. The hero can be medevaced to a hospital on a military helicopter. What would the medic do in the field? I don’t want the bullet to penetrate the chest wall, but would the medic check for pneumothorax and if so how?

What would happen at the hospital? How long would he be hospitalized?

I’ve read and re-read about pneumothorax and hemopneumothorax, but think that might require too much recovery time and be too much for him to qualify and be able to pass the physical. I’ve done some research on pulmonary contusion but am a bit overwhelmed with the possibilities of the use of continuous positive airway pressure and high-frequency chest wall oscillation. And the long term recovery.

Since I really don’t know what would be best as a gunshot wound that my hero can recover from and pass a physical in a few weeks, I really need some guidance and specific information that can easily be explained in a romantic suspense novel. I’m hoping this “bullet grazes the rib” scenario is workable. If not, what should I consider instead?

Jordyn Says:

Thanks so much for sending me your question, Virginia.

I think the simplest thing to do is to have the bullet graze his chest. It could potentially hit the rib, break it, and ricochet away. Leaving a nasty gash with a broken rib underlying but nothing else injured. Generally, a fractured rib will heal in 4-6 weeks so he will have pain and limited movement until then. The worst pain will probably be in the first 1-2 weeks and then should taper off after that.

As far as the military medic assisting off duty. I think it’s fine if he has a small first aid kit that he could dress the wound with. He likely would not be carrying an oxygen tank, etc. So the dressing to control bleeding is necessary. Lots of emergency medical types might have a small kit in their car (I do), but not an oxygen tank or a way to deliver oxygen to the patient.

The military medic could check for a pneumothorax by listening to your hero’s breath sounds. Clear and equal breath sounds bilaterally generally indicate no pneumo (though a small one could still be present). It will hurt to take deep breaths if his rib is fractured.

If he’s transported by a military medevac then they could start oxygen, an IV, and give some IV fluids. Place him on a monitor to keep tabs on his heart rate, breathing, oxygen levels, and blood pressure.

In the hospital, he’ll get chest and belly films and possibly a CT of his chest and abdomen. If it seems like a fairly benign wound, the wound could just be irrigated with a lot of saline and sutured closed. He needs an updated tetanus shot if he hasn’t had one in over five years.

If his breathing is good and he suffers just one cracked rib, there is likely not enough injury criteria for him to be admitted into the hospital. He’d likely be observed in the ER for several hours to make sure everything is okay. He’d be sent home with a short course of narcotics (like three days) and instructed to take over the counter pain relievers to help with the pain as well. He should have limited activity but not be bedridden. He’d be encouraged to take deep breaths (usually at every commercial break if watching TV) to prevent lung complications because patients don’t like to breathe deep when they have a cracked rib.

Hope this helps and good luck with your story!

Author Question: Bullet Wound to the Chest

/ Jordyn Redwood / Leave a comment

Gwyn Asks:

I’m writing a scene in which a cop is injured during a confrontation with a suspect.  I’d like to tell you about the scenario I have in mind and hopefully you can tell me how realistic it is.

ammunition-2004236_1920Cop, mid-thirties, in excellent health and physical condition is shot with a low caliber bullet from about 10 feet away.  The bullet hits his chest, goes through the lung and exits out the back.  He’s got colleagues nearby who administer basic first aid and the EMTs get there within 5 minutes.  Say about 15 minute drive to the hospital.  They radioed ahead so the hospital is expecting them and has an OR ready.

First of all, what are the chances of survival?.  Second of all, assuming survival, what are the chances (best case scenario) of full recovery – to the point he can return to active duty.  How long would the recovery time be, how soon would he get out of the hospital, and what complications — pneumonia, blood clots, etc should the doctors be worried about?

Finally, if a full recovery is highly unlikely, are there little changes I can make to the scenario to make it more likely?

Jordyn Says:

Hi, Gwyn! Thanks so much for sending me your question.

In short, this is a survivable injury.

You don’t specify in your question whether this police officer is shot in the right or left chest. Right chest would probably be preferred as there are less vital structures on the right side of the chest then the left.

ambulance1You give your victim immediate first aid and EMS responds quickly. Keep in mind that you’re going to need a paramedic to respond to give more advanced field procedures. A basic EMT is limited in what they can do— CPR, wound dressings, assisting the patient with some of their own medication administration. Depending on the state, some EMTs can start IVs, so if your novel is set in a specific location then I would research this for that area. Assuming he has a paramedic respond then he’ll get an IV, IV fluids, oxygen, and possibly pain medications. Of course, a set of vital signs and cardiac monitoring.

In an urban setting, a drive time of fifteen minutes to the hospital seems a little long. If a rural setting then you’re probably fine but you might need to adjust there as needed.

A bullet passing through the chest is likely going to puncture and deflate the lung. This character will need a chest tube to get the air out of his chest and reinflate the lung. A chest tube can be placed in the ER. This patient would get a CT scan of his chest. If the medical team isn’t worried about any other injuries than this patient may not even need to go to the OR.

A patient with a chest tube will need to be admitted into the hospital. How long it takes the lung to reinflate depends on the size of the pneumothorax or the degree to which the lung has collapsed. Generally, a patient’s chest tube is connected to a drainage box that uses suction to help the lung reinflate. Patients with this type of injury will get daily (or every other day) chest x-rays to see how the lung is expanding. After the lung is fully expanded, the suction is stopped, but the box remains in place. This is generally referred to as placing the chest tube to water seal.

If the lung stays expanded to water seal for one to two days then the medical team would feel good about removing the chest tube. Then the patient would be observed for another one to two days to make sure the lung stayed reexpanded.

Pending any complications, you’re looking at a hospitalization of 4-7 days. Pneumonia is probably your more likely complication. Having a tube in your chest hurts. Because of this, patients don’t want to take deep breaths. This can lead to the smaller air sacs in the lung staying collapsed and trapping bacteria which could lead to pneumonia.

If you add a complication like pneumonia, then you’re easily adding another one to two weeks that he’s out of commission.

If you just stick with a “simple” collapsed lung I would say he’d be out of work for about two weeks. He won’t be physically 100% of what he was before the injury but he should feel back to his physical baseline in about a month.

I would say he can work, but he’s going to have some physical limitations. It would be up to his department what his physical capacity needs to be before he can return to work. Half days at a desk job is not unreasonable for a few weeks.

He’d likely become short of breath during any exertional activity (like running after a bad guy). However, considering his physical shape, he should bounce back fairly quickly.

A nice overview can be found here.

Hope this helps and good luck with your novel!

Author Question: Stab Wound

/ Jordyn Redwood / 2 Comments

Sandi Asks:

Where can you place a stab wound that wouldn’t instantly kill your character, but keep him around for a few hours?

diagnosis-1476620_1920-1Jordyn Says:

You have a couple of options here. One would be a stab wound into the right side of the chest. This could partially collapse a lung and cause some bleeding as well. Think of the lung as a balloon. A small nick to the lung could cause it to slowly leak air into the chest, keeping the character alive for a few hours, but killing him in the end if the collapsed lung isn’t treated. The more collapsed the lung is, the less it is able to function. The more air that accumulates in the chest, the more it will push other structures.

We call this a tension pneumothorax.

Imagine the right chest is now full of air. Air will keep building unless it is given a way out (like a chest tube) and can actually squish the heart and lungs on the other side of the chest to the point where the heart may not beat anymore.

If a tension pneumothorax is left untreated, this will cause the patient to die. They may die from blood loss, or low oxygen levels, or from the heart being impinged to the point where it can no longer beat.

Why not a stab wound to the left chest? This has an increased chance to kill instantly because you have the heart and several large blood vessels that come off the heart that sit there. Can anyone say aorta?

Another option would be to have a stab wound to the belly. All sorts of stuff in there. If you wanted the character to die in a few hours, this could happen from untreated bleeding. There are two organs that sit in your abdomen that have a rich blood supply— the spleen and the liver. The medical term is highly vascularized . . . meaning rich with blood supply. You could also have an infection set in and this could keep him alive for a couple of days until he is overwhelmed by sepsis.

What signs and symptoms would a patient with a collapsed lung (pneumothorax) have? What’s the difference between and sign and symptom?