to Emergency Medical Services, nurses and junior doctors

This article is written jointly with Dr. Shubhoshree Mitra*

Abstract

This paper delves into the depths, whether Chest drain training given to nurses, Emergency Medical Professionals of Eastern Cape and Paramedics would reduce the time period of Morbidity and Mortality.  Survival of patient being inserted Chest drains in prehospital settings will definitely reduce deaths due to chest injuries.

I worked as a trauma surgeon and gender violence expert in a regional hospital in the township of Mdantsane, Eastern Cape, South Africa. Mdantsane is the second biggest township after Soweto.. Trauma is a major burden of disease in our hospital in Mdantsane. For more than thirty years, I worked in the Orthopaedic and Trauma sectors with my junior colleagues in day and night calls.  Polytrauma which includes chest injuries were the greatest challenge as time consuming for inserting a chest drain sometimes on both sides and rejuvenating with blood through one arm to compensate the loss of blood. Due to the time interval by the Emergency Medical Services, Eastern Cape, some patients were brought dead.

It made us think if the chest drain procedure if given to the EMS on a patient in out of the hospital areas and a one litre Ringers Lactate bottle flowing in one arm with mask oxygen support, it will significantly reduce the mortality of chest injuries.

Cause of Chest Injuries

• Motor Vehicle Accidents due to direct impact on the steering wheel
• Interpersonal Violence and Intimate Personal Violence by sharp and violent object.
• Alcohol and drug induced violence
• Gunshot injuries
• Fall of an elderly man/woman on the road and hit on the chest by a sharp object
• Cricket and Rugby Injuries
• Boxing Injuries

Time Consumed for inserting the Chest drain and post insertion Xray is more than one hour. Handing over the patient to the general surgeons takes more than one hour as there is a scarcity of medical doctors in the Department of Surgery. So the total time consumed from the time of injury to a definitive treatment is more than six hours. The cause of mortality in most such cases are due to Haemorrhagic Shock.

Causes that Chest Drain Insertion is not being taught

Nurses, junior and senior do not wish to learn and sometimes do not assist the surgeon.

Nurses and Paramedics do not wish to learn as they believe that they might get involved in Medicolegal problems if the patient dies.

Emergency Medical Professions of the Eastern Cape do not do it as they are not trained to do so.

Junior Interns and doctors do not do it as they have not done the Advanced Cardiac Life Support Course and have not been trained by   their senior colleagues and head of the department.

Continuous Training Courses are not possible as the Superintendent General of Health, Eastern Cape and the Chief Executive Officer gives a statement that the Department of Health lacks money to give training or to recruit new Medical Officers. Thus numerous medical doctors remain unemployed in spite of having the right training.

Presentation at the Emergency Department

• Bleeding and red bruise marks on chest either front or back
• Fast Breathing, Sweating, Bleeding from the chest both internal and external
• Garrulous and Dementic
• Skin pinch time is more than two seconds
• Needs Restraining
• Chest drain tray prepared and then leaving the surgeon to do himself alone
• The gush of blood from the pleural space into the bottle and the rise and fall off the blood in the bottle makes us know that that the tube is in the right space.
• Suturing the tube at 4th Intercostal or the 5th intercostal facing the tube downwards and by blunt dissection

The rural areas which feed on to our hospital are more complicated as the nurses nor the Emergency Medical Services can insert a chest drain

Conclusion in South Africa to the technique of inserting chest drain

Supervision - Country wide training of nurses and Emergency Medical Services

Removal of Trochar from all chest drains. Nurses stationed in rural clinics without doctors must be our first aim. This must be shown to the Health Professions Council of South Africa and a rule must be implemented. The burden of trauma will come down considerably if such an advice is implemented.

* Dr. Shubhoshree Mitra is a Community Service Medical Officer and does calls at Uitenhege Hospital, Eastern Cape, South Africa.

References 

1. Severe blunt thoracic trauma: Differences between adults and children in a level I trauma centre SAMJ, S. Afr. med. j. vol.105 n.1 Pretoria Jan. 2015

2. Characteristics and outcome of traumatic chest injury patients visited a specialized hospital in Addis Ababa, Ethiopia: A one-year retrospective study. 

3. Pre-hospital intercostal chest drains in South Africa: A modified Delphi study