Tougher than a chest tube.

Historically, the absolute toughest patients I have ever treated have been 9 year old girls. Tough as nails, they are. They have held that position unrivaled, unchallenged really, until yesterday afternoon.

I got the call late afternoon that a patient had come from his place of work after a brick had fallen on him, on his chest I was told. Nothing concerning conveyed, so I asked for a chest xray and finished what I had been working on before making my way over to the hospital. My calculated slight delay had allowed time for the chest xray to be completed and I pulled that up to view on arrival. What I saw was not the patient that had been described to me over the phone; a partially collapsed lung on the left side (~50% down), with air leaking into his chest wall and blood filling his pleural cavity. Pushing my chair back I whirled around to find this impending disaster. My eyes scanned the benches along the wall that sat the Rea (emergency) patients. Nothing screaming "help me," I started scanning back up the row this time, perhaps slower, slightly more focused, and I still almost missed him again. He sat almost at the end, no overt sign of distress conveyed by body language. He sat up tall, hands resting gently on his legs, no grimace or line marring in his young face. But his nares flared, I caught it in passing, and turned full focus on him. They flared again.

He was indeed my patient. Fourteen years old and a bricklayer by trade. Now the story was he had fallen while at work and landed on that left side. Perhaps a brick fell on him before, or after the fall, but either way didn't really matter. I explained the situation, and the need for a chest tube. My explanation felt hasty, and I wondered if they would question my recommendation, requiring further clarification. No such request was made, and no hesitation was demonstrated.

The membrane lining the lungs and the pleural cavity is a highly sensitive tissue. Hearing the screams and/or incomprehensible syllables uttered by patient's on the receiving end of the chest tube, leaves no one in doubt of that fact. Knowing this, I never have, and if able to, never will skimp on the lidocaine for a chest tube placement. In the US, even with my generous lidocaine, I found it necessary to routinely tape a patient's arm to the bed above their head to prevent them from inadvertently punching me during the procedure.

As I directed my patient with simple phrases, he made eye contact with me and nodded understanding. I moved his arm above his head opening his left lateral chest to me. He didn't fight or resist, and somehow I knew he wouldn't move it. Chest tube placement went smoothly, without a flicker from the patient. Then the trouble came. Attempting to connect the end of the chest tube to the waterseal proved futile as the two ends were mismatched. I had eyeballed it before starting and made the assumption they could be coaxed together. I had been wrong, and until I could connect the tube this 14 year old boy lay there breathing with one lung as the second was now completely collapsed unable to compete with the pressure change created by the hole I had just made in the side of his chest. My internal voice was not too pleased with myself, to put it mildly. I kept calmly working while instructing the nurse to find a possible adapter. In a flurry of activity, and now drawing new attention from hospital personnel, an assortment of options were brought to bedside. Before long (even though it felt much longer at the time) the tube was secured and successfully connected with an adapter and a second adapter for the first adapter jerry rigged together. Throughout it all, the patient still had not offered even a flicker of reaction. Even when I knew it was painful. Even when I knew he was struggling to breathe. Not a peep. Not a wince.

Nine year old girls and fourteen year old boys = the toughest patients I have ever seen.

Much Love.