Clinical Case 115: Pneumothorax puzzle

This case was interesting for a number of reasons.  It starts with a 50 year old lady whom has been assaulted.  She says she was kicked in the head and chest.  In ED she is looking sore but stable – and it was felt that she had enough mechanism to warrant a CT of her head and neck.  On the neck CT it was noted that she had some surgical emphysema on the lower slices – so she stayed in the tube for a chest scan too!  Here it is:

Pneumothorax = Tense CT!


Now – I know what you are all thinking…  that is a CT image that should never had been captured!  We have all heard the addage that you should always pick a tension clinically and never need to image it… but…  the honest truth is that we just are not that good at picking pneumothorax clinically.  As you know I am an ultraosund tragic – and I believe we can certainly pick em with a quick chest probe.  However, relying on clinical exam is just not, well, reliable.

In recent years one error that I have seen creeping into my practice is the tendency to “fast-track” trauma patients to imaging where appropriate without completing a fully thorough secondary survey.  There are a lot of reasons (? excuses) for this:

– trying to get the imaging done in office hours,

– trying to get patients out of collars ASAP,

– relying on second-hand info via handover which may be innaccurate….

– search satificing. Stopping at one major injury!

So my “lesson learned” here is to be systematic and make sure that you are imaging everything that needs imaging and that you have excluded the big “killers” before settling for a CT.

OK – back to the case.

A chest tube was placed and the pneumothorax decompressed.  Post ICC films showed a well expanded lung.  Our patient was admitted to the ward.  Lets jump to the next day…..

Our patient starts to deteriorate.  She is becoming more hypoxic with tachypnoea.  What is going on?

Well there is a few possibilities.  The chief concern was that the tube was occluded / dislodged resulting in reaccumulation of the Ptx.  So another CXR was performed…

Take a few minutes to look at this CXR.  It was reported by the Radiologist as “recurrence of pneumothorax on the right, with overlying subcutaneous emphysema mimicking lung markings.”

There is no recurrence of the pneumothorax. Clinically: the ICC is “swinging” but not “bubbling” – so the tube is patent and CXR shows it is still intrapleural. There is of course considerable mediastinal shift – which is due to the loss of volume on the left side which is collapsed.

Of course – Ultrasound will be useful. The left side is going to be tricky as there is a heap of SubQ emphysema – so the pleura will be hard to visualise. However, if you can find a gap you can see sliding, great. Really the utility of US is to define the collapse on the left side – consolidation, is there an effusion?

So here is where it gets easy – back to basics. The problem here on ultrasound was consolidation with likely atelectasis. The nurses noted the patient was too sore from rib fractures and had been positioning herself right-side up with some haemoptysis. It was very likely that she had plugged some largish bronchi with blood and debris. So we engaged a trusty expert chest Physio to bang out some mucus and blood. Provided good analgesia and got her up and walking. The next day – here lung was re-expanded and her hypoxia was resolved

OK –  let’s hear your comments.  I you were at #SMACCUS last week then you will have a distinct advantage over the other readers as this case was put up in a session there and discussed.

There are so many potential errors that we can make in even the simplest of cases.  Trauma is a complex scenario with information overload, serious sequelae and time critical decisions to be made. So over the next few months I am hoping got run with a theme of “common errors and their mitigation”.  Hoping to have a few special guests on to help show how we can avoid the pitfalls and do better on the floor.


Dr Dave Forster: A tough airway made easy

Welcome back!  Apologies for being away for a few weeks.  You may know that a large part of the FOAM community was attacked, hacked and disabled by malignant robots last month.

Thanks to Dr Mike Cadogan and his band of merry men we are now back online along with other awesome sites that fell victim to this pillaging ( KIDocs, St Emlyns, The RAGE podcast, etc).

In case you missed the podcast was still alive during the carnage over at the LITFL bunker… and I managed to record a little chat with my local hero and fellow Broome Doc – Dave Forster.

Dave is a man of many talents, he is a gadget guy = remote controlled airplanes etc.  He is therefore a master of the Atari and fiberoptic bronchoscope!  And many don’t know this – but if you download the free “Introduction to Bedside Ultrasound” textbook and check out the SUSSIT chapter – his is the really, really hairy chest used for still images.  (And yes, he does routinely wear a Bon Jovi T-shirt to work… overdressed for Broome some might say 😉

Dave F

What a man: sono-model and master of the airways.  You can even follow him on Twitter after a few years of arm twisting he is on there @DavidFo00088350

In this podcast he outlines his approach to a really tough, “back to the wall” case where an airway needed to be placed in a really difficult scenario.

Sure there are some great technical pearls in here, but for me it is all about the team and how a confident, communicative leader can turn a shit storm into a sleigh ride.

Have a listen HERE.  Then spend a moment thanking Mike Cadogan and his team for all this stuff that you, our fantastic audience, get for free.  Without folk like Mike we would not have FOAM… and the Medical world would be a bigger, emptier and less safe place.


PODCAST: Shared decision making

Shared decision making.

This is one of the hot concepts in healthcare right now.  It is not new – but it is being embraced in many fields as a part of the trend towards more evidence-based practice and the changing culture of medicine where “doctor knows best” is no longer an acceptable platitude.

If you read or listen to a lot of the FOAMed resources – then you will hear a lot of discussion about engaging our patients in a shared decision making process.  Whether that be to help us decide on the right investigation, treatment or indeed to make the decision to not investigate or treat a given problem.

Here is the ideal model as taught in most EBM courses:


Now that is a nice diagram – and it certainly sounds like a good idea.  Out with paternalism, in with patient choice, add a sprinkling of evidence and voila – we can all go home happy.

But….. and there are a few here… how does it all actually work on the ED floor, in the busy GP clinic or specialist suite?

Have a listen to the latest Broome Docs podcast – and hear my dissection of how it could, should and might work in everyday practice.


Being A Doctor’s Doctor – Penny Wilson and Geoff Riley

Have you ever treated a fellow doctor?  How did it feel?  Did you feel confident or intimidated?

Consulting and treating our colleagues can be really tricky.  The dynamics seem a little alien, there is a huge risk of assumption leading to errors and of course there is always the nagging doubt that you may need to go against their wishes in some circumstances.

Dr Penny Wilson @nomadicgp – a regular in the O&G corner of Broome Docs and now the co-creator of the Bit & Bumps podcast has chipped in this week.  She has interviewed Prof. Geoff Riley – former rural GP and Psychiatrist – who was until recently my boss at the Rural Clinical School in Western Australia.  Geoff has developed a practice over the years as a doctor’s doctor.  He has treated many fellow doctors including some with significant impairment.

So sit back and relax, grab a cuppa and listen to this fascinating discussion about how we ought to approach being a GP to another doctor – and also how we can be better patients when we go along to see our own family doctor.

Yes – we should all have a GP.  Do you see one? If not – I would love to hear why – hit me on the comments below.

Onto the podcast DOWNLOAD HERE


Renal Colic Scans with Dr Adrian Goudie

Patients presenting to the GP or ED with flank pain, colicky pain or pain with haematuria are pretty common.  We know that a lot of these folk will turn out to have the dreaded kidney stones.  We all have our own ways of deciding how to treat these patients.  You may be aware that in September  a big paper was released in the NEJM titled Ultrasound vs. CT for Suspected Nephrolitiasis.  For many ED docs this paper just might be a game-changer.  This was the first really big trial which looked at the bedside US vs. formal US vs. CT for the initial workup of this group of patients.  And it seems to suggest that bedside US is a valid first test for most patients.

As a GP I think this is potentially a big change – if we can scan at the bedside in our clinic with the modern machines – we just might be able to do a pretty fair job of managing simple, uncomplicated renal stone disease without ever needing a hospital – that would be nice!

Anyway – I have been wanting to pick the brain of a much smarter ultrasonically-enhanced doctor about how this changes our practice in 2014 – so I managed to enlist the help of Dr Adrian Goudie [ED Physician, Ultrasound Village teacher, SMACC Sonowars combatant, Ultrasound Leadership Academy Professor and immediate past President of the Australasian Society of US in Medicine…  and great bloke! ]

We had a natter about the paper, his practice and the pragmatic approach to patients with potential stones in the ED (or GP clinic).

Here is the podcast:


Adrian has a really nice set of “rules” to guide us when working up suspected renal colic patients.  It goes something like this:

  1. Treat the following groups with caution – you may want to be more aggressive with your imaging if the patient has:
    • Known renal failure, or new renal failure
    • Known congenital anomaly or single (transplanted etc.) kidney
    • Signs of infection / sepsis / obstructed pus is bad.
    • Extremes of age – you are just more likely to find other pathology that you don’t want to miss
  2. As a routine have a look at the aorta – this is low-hanging fruit and an important one to not “miss”.
    • You should also consider the gallbladder, uterus, ovaries, testes and even the appendix if the clinical picture fits.
    • Think outside the KIDNEY BOX – particularly if your renal scan is normal.

You can also check out an older Broome Docs Case [To Frolic with Colic: Case 035]  where we looked at the value of “haematuria” in the investigation for renal colic.  It is interesting to go back a few years and see the smart docs who anticipated this research with their comments- Dr Goudie was one of them!

Also check out the Renal Ultrasound talk from Matt Dawson at Castlefest a while back. So you can see what stones etc look like.

There is a great “Cheat sheet” for reference when scanning from my friends at the Sonocavge HERE – Thanks Dr Goudie and Dr Rippey.

Let me know if this will change your practice…. or not.