A fish induced pneumothorax: dilemmas in the remote management of a sucking chest wound
BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7072.1617 (Published 21 December 1996) Cite this as: BMJ 1996;313:1617
- David Berger, ex-senior medical officera
- Correspondence to: Dr D Berger, 1 Yelland Cottages, High Bickington, Umberleigh, Devon EX37 9BX.
The call came, as such calls always do, at dinner time. It was Jenasi, the very capable nurse from Seghe clinic in Marovo Lagoon, on the radio. A man had just been brought in, having been attacked by a barracuda earlier in the day. He had a large gash in his chest, through which air was passing in and out as he breathed, but his observations were stable and he was not cyanosed. Hmmm.
The sun had just set, which in the Solomon Islands means no evacuation, by air or otherwise, until first light. Should the wound be packed to stop the movement of air or not? We conducted a straw poll among the doctors: our ex-army officer said it definitely should be, as otherwise he was in danger of developing paradoxical breathing; our general practitioner surgeon said probably not; and the Swiss orthopaedic surgeon in the capital, who we contacted by phone, said definitely not as there was no possibility of putting a drain in should he develop a tension pneumothorax and he was currently well. (My own contribution was only to man the radio and whine lamely that such matters did not really form part of a physician's training.)
In the end it was decided to advise the nurse to leave the wound open and give some intramuscular antibiotics, while I flew down the next morning, equipped to put in a chest drain (or at least a recycled suprapubic catheter, which was all we'd been able to rustle up). Very kindly the pilot agreed to hold the flight for 30 minutes and I was rushed over to the clinic by canoe.
Giving instructions over the radio, in Pidgin, is a haphazard affair at the best of times, and I was thus only mildly surprised to find that the wound was swathed in cotton wool and bandages. However, there was no movement of air and the patient looked very well, clinically having only a small axillary pneumothorax.
Now I had a problem: he had remained well for over 18 hours with no active intervention on my part, and I was faced with two possible ways to render him unwell. I could try to drain his pneumothorax, thus making him safe to fly, but possibly doing him some mischief in the process; or I could fly him out as low as possible, risking the possibility of a “functional” tension pneumothorax as the air in his pleural cavity expanded with increasing altitude.
The patient (in towel) and his wife in the canoe at the lagoon entrance
The minutes were ticking by rapidly, and I was sweating more than even the 35°C heat warranted. What eventually made up my mind was the swell: as we flew down I had observed from the aircraft that for the first time in weeks the swell had moderated and a canoe trip the 60 odd miles to the mission hospital up the coast was a possibility. I consulted the nurse, who agreed that it could be done and so I sent word to the pilot to continue his flight to the capital without us.
A canoe was duly readied and we spent the next five hours battling against a sea which was, needless to say, much bigger than it had appeared from the aeroplane. When we finally arrived an x ray revealed the pneumothorax to be as suspected, and we inspected and photographed the wound, which had what looked like a piece of lung protruding into it, after which we dressed and covered it and put the patient to bed (he was still refusing anything for pain, as he had been since his arrival at the clinic the day before). The next day he had a little difficulty in breathing, and the pneumothorax was somewhat larger but a decision was made not to drain it unless he worsened, and over the next few days he made a rapid recovery, the wound being closed by the excellent New Zealand mission doctor on the sixth day after the attack.
Questions posed by this case are:
What advice should have been given to the nurse over the radio?
Leave it open
Pack it
Leave it open and pack it if he deteriorates
Pack it and uncover it if he deteriorates
None of the above
Would it have been safe to fly him out and, if so, up to what altitude?
How stupid was it to leave his wound uncovered for a protracted period in the hospital while we sauntered off and fetched our cameras, thus contributing to an increase in the size of his pneumothorax?
A little
Moderately
Extremely
Answers to the editor on a postcard please….
Manhandling the canoe across rocks in the lagoon passage
Footnotes
-
The man was actually attacked by a barracuda which jumped out of the water and hit him in the chest while he was standing waist deep in the lagoon in broad daylight, an occurrence which the locals agreed was practically unique. However, pneumothoraces due to fish are not uncommon, and the mission doctor had seen several in his four years in the Solomons. The islanders like to go fishing at night in dugout canoes using torches. These attract fish known as garfish (or long toms), which fly out of the water, sometimes impaling their long, sharp proboscis in the unfortunate fisherman's chest. On one occasion one had penetrated a fisherman's orbit and he died shortly after reaching the hospital.