It was a classic trauma case, requiring a full trauma survey, x-ray series and trauma labs. He was holding his right rib cage, screaming in pain when his family drove up outside the ambulance bay entrance. An EMS crew was in the department waiting to transport a patient, so they evaluated him as if they were on scene, extricated him from the passenger side, started IVs, pain meds and immobilized his C-spine.

The inital xray series was extremely suspicious for a pneumothorax, but rib fractures were hard to see. Once his cervical spine was radiographically cleared, I sat him upright in bed for a better chest x-ray. This one was just perfect…it clearly showed a whole rib cage full of fractures with an accompanying pneumothrorax…the largest pneumothroax I’ve ever seen! It would have eventually turned into a tension pneumo, but thankfully I had enough time to call in a CRNA to help sedate him and to go raid the OR supply room for a skin prep kit, OR gown and sterile OR towels.

By the time he was sedated, the trauma surgeon had arrived to watch me put in the chest tube as I had a galley of six observers. Considering there are at max three people staffed in the ED at any one time (a doc, a nurse and a unit clerk), it was a fair sized audience.

THe inital puncture into the chest wall had the classic rush of air, and the chest tube went in and secured easily. The post procedure x-ray was satisfyingly absent of a pneumothorax and clearly showed the chest tube in great position.

I can’t really explain what it was about this case tha tmade me feel good. First of all, I DID soemthing to help someone. I didn’t just perscribe some meds or provide reassurance or transfer someone to an orthopedic surgeon or eye doctor. I put in the chest tube that re-expanded his lung. THere was absolutely no question that it was the right thing to do. The before and after pictures were dramatatic.

The small ER makes cases like this fun. I performed some minor surgery that inolved me having my hands (OK, just my fingers) INSIDE of a man’s chest wall. That’s always cool. It makes me feel priviledged and powerful at the same time. Sure, it’s an easy procedure…for an ER doc, critical care doc or a trauma surgeon, but for everyone else, it’s magical.

Tonight, I was a magician.