Indexing Title:
HTURINGAN’s Medical Anecdotal Report [05-05]

MAR Title:  Difference in Technique

Date of Medical Observation: 01 June 2005

Narration:

 It was my second day in PGH after accepting a fellowship position in Thoracocardiovascular Surgery, as a rule all thoracostomies should be done by TCVS or at least referred to the division and assigned to second year GS TCVS rotators,  however in this case a GS resident opted to do the CTT and apparently referred the case to TCVS after the patient eventually developed retained hemothorax.  It seems the technique used in the institution is that after skin incision, sharp dissection is done with mayo scissors until it punctures the  parietal pleura.  This was performed on this particular patient, however after the mayo entered the pleural space, he opened the scissors to enlarge the hole for the tube and closed it as he exited the wound inadvertently cutting the lung parenchyma as he did so, thus the bleeding post CTT.   The patient underwent thoracotomy.

Insights (PHYSICAL, psychosocial, ethical) ,Discovery, Stimulus, REINFORCEMENT:

We at OM use a blunt instrument like a Kelly to open the parietal pleura.  This technique serves its purpose most of the time, however for very muscular and obese patients, I personally use a blade from skin to fascia to give me a clean cut and ease dissection, once the fascia is adequately opened, I  use a Kelly to bluntly open the parietal pleura.  If scissors are at all to be used (as is the practice in this particular institution) to puncture the pleura, as it is opened to enlarge the hole, it should be left open as one exits the wound to prevent iatrogenic injury to the lung.