Chest Injuries in trauma: The major killer in India after road traffic accidents: Seat belt should be worn in cars and buses

Breathing and Chest Trauma

Dr S Chockalingam

One of the major killer injuries is Chest Trauma. In fact the chest trauma is the commonest killer for a driver behind a steering wheel especially when not wearing a seat belt. Chest trauma is one of the injuries, which is treatable in a patient who can reach a hospital alive. Appropriate treatment can save many lives if recognised promptly. This appropriate treatment is often a simple intervention as opposed to a thoracotomy. Any doctor irrespective of their specialist interest should safely perform these simple interventions.

The following content focuses briefly on the essential anatomy, physiology of the chest. The main focus is then on recognising these injuries and acting swiftly to save one’s life. Early recognition of these injuries will also help in preventing late deaths.


Essential Anatomy:

The Chest is comprised of the lungs and pleural cavity, heart and pericardium, mediastinum and its contents, chest wall with the ribs and the muscles, diaphragm.

Essential Physiology:

The function of the chest is mainly two fold, gas exchange chamber and a safe haven for the heart and major vessels.

1.The lungs with the bronchial tree and alveoli function as gas exchange chamber. Oxygen gets in to the circulation and CO2 is excreted. The Chest Wall with the pleural cavity and the diaphragm acts as the motor behind to facilitate the gas exchange.

2. A safe place to keep the important organ, the heart and the main blood vessels.

Recognition and treatment of the chest injuries:

In our Medical School, we are taught the art of clinical Medicine. These would be taking a detailed history, thorough examination and ordering appropriate investigations before instituting treatment. The management of trauma is a clear exception to this approach. Hence we have to recognise the injuries and treatment the life threatening injuries before proceeding to the next step. This is most appropriate in chest trauma.



Recognition of Chest Injuries:


A patient who had trauma should always have the primary survey starting with

Ensuring a patent Airway with Cervical Spine Protection before moving on to the chest injuries. The injuries to the airway presents with similar features to the chest injuries. Airway obstruction with
1. Strider
2. Inability to talk
3. Broken tooth
4. Secretions in the pharynx
5. Gross swelling of the neck

Should be managed before moving on to the chest injuries.

The recognition of the chest injuries is essentially two fold.

1. Assess the breathing
2. Assess the cardiac function

These are done by

1. Look
2. Feel
3. Percuss
4. Auscultate
5. Use adjuncts

Look:

1. Equal chest wall movements
2. Engorged veins in the neck
3. For open wounds
4. Abnormal chest wall movements

Feel:

1. Tenderness
2. Crepitus
3. For equal chest wall movements
4. Pulse rate
5. Tracheal position, midline or deviated



Percuss:

1. Hyper resonance
2. Dull note on percussion

Auscultate:

1. Air entry on both sides
2. Heart sounds
3. Abnormal sounds suggesting obstruction
4. Blood pressure

Adjuncts:

1. Pulse oximetry, Pulse, Blood Pressure assessments
2. Chest X ray
3. ECG

Serious Injuries to be recognised promptly:

1. Conditions which affect mainly breathing
a. Massive air collection around the lungs: massive pneumothorax
b. Massive blood collection around the lungs: massive hemothorax
c. Chest wall injuries leading to flail chest
d. Open chest wound with pneumothorax

2. Conditions which affect the heart and circulation

a. Massive blood collection around the heart: Cardiac Tamponade
b. Massive blood collection around the lungs: massive hemothorax


Treatment as you recognise these serious injuries

1. Needle decompression and chest drain for massive pneumothorax
2. Cover open wounds with air tight dressings immediately
3. Resuscitate with oxygen and blood prior to
4. Chest Drain for massive hemothorax
5. Ventilate with oxygen, ambo bag for flail chest before intubation
6. Needle decompression of pericardium in rare instances

The rest of the chest injuries can wait until we complete the primary survey and management of other major injuries.
Other Injuries, which will become life threatening in due course and hence should be recognised and treatment started. These are

1. Pneumothorax which is not massive
2. Hemothorax which is not massive
3. Major airway injury of tracheobronchial tree
4. Blunt injury to the heart
5. Major vessel injury such as aorta
6. Mediastinal often open injury
7. Injury to the diaphragm
8. Multiple rib fractures

Please remember the power cable for chest wall function is “the intercostals nerves and the phrenic nerve and the brain” ultimately. Hence any injury to the spinal cord, brain and the phrenic nerve will affect breathing even when the chest wall is not injured.

Summary

We have to be familiar with understanding of the following features associated with major chest injuries

When observing the patient

1. Chest pain and air hunger
2. Distress in breathing
3. Sucking open, but often-small wounds in the chest wall.
4. Flail chest

When eliciting the signs

5. Absent breath sounds
6. Engorged neck veins
7. Subcutaneous emphysema
8. Tachycardia and Hypotension
9. Deviated trachea
10. Muffled heart sounds
11. Cyanosis

When assessing with
12. Abnormal saturation with Pulse oximetry
13. Chest x ray abnormalities in trauma
14. ECG changes of blunt cardiac injury

The key message of this review on Chest Trauma is never underestimate these injuries as often these injuries kill a patient within few hours of injury and if not will adversely affect the outcome in the first few days of admission to the hospital

Innovation in Orthopaedics and at KMC Speciality Hospitals: 1. Epsom to Trichy: Chockalingam

This is a custom spica table for applying hip spicas in children. There are so many different methods to attach a support for the child when applying hip spicas. The best one i have used is one introduced by my predecessor and former Colleague Mr[Dr] Philip Cheong Leen. We worked at Epsom General Hospital,Epsom, Surrey, UK. This was simply a miniature iron board made of metal.

So the concept was not mine but to bring to my hospital, i felt it was necessary. I have done hip spicas for femoral fractures, DDH and so on. I gave the measurements and idea to our Theatre senior ODP Mr Jayaraj and he executed very well. What you then see is what the output of the carpenter at our hospital and painting was done aptly in a pink colour.

Regards


Chockalingam

Academic Input from chockalingam

This is the work output of nearly five years of working on knee replacements at Royal London Hospital, London on Freeman Samuelson Knees. I always treasure the time I spent with Mike Freeman and Gareth Scott

This is the work output of my association with Mike Bell, Senior Consultant Paediatric Orthopaedics at Sheffield. I will always cherish the training given by him in this area along with other consultants in UK

This is the work output of a case report on skin burns in Orthopaedics

5th June 2011: Sports Injuries and Advanced Arthroscopy Awareness meet Trichy

Since 2009 January, We have done more than 150 thereupatic Arthroscopic Surgeries. These include Knee Meniscal Surgery, meniscal repairs, Anterior and Posterior Cruciate Ligament Surgery, Shoulder Decompressions, Rotator Cuff repair and Stabilisation, Ankle , elbow and wrist thereupatic arthroscopies. the indications even included rare conditions such as arthroscopic treatment of intra articular hemangioma and removal of bomb shrapnels arthroscopically.

When such work is being done in a hospital in a city like Trichy, you feel for the people who are not aware of the facilities being available and hence this year we took Arthroscopic Surgery , in other words the key hole surgery to joints for awareness program.

Sports being increasingly taken up by the younger generation and road traffic accidents constantly presenting with joint injuries, we decided that this would be the time for us to promote the awareness.

Please go through the picture attached with the details of the awareness program and i will post few pictures as well

Regards

Chockalingam

Part 2:Doing a job vs completing a job: concept of professionalism and sincerity and how money clouds both.

When I went to pay the Electricity Bill in Trichy, there were four queues. I joined the first outer queue without giving any thought. Then I noticed the queue on the inner two queues moved swiftly and the outer queues did not move as fast as one would expect. The obvious inference anyone would make is that the persons at the desk serving the public are efficient in some counters and may be we joined the wrong queue.

But why should only the outer queues move slowly whereas the inner queues were otherwise. Chances! May be and they were not in this instance. The outer queues had constant disturbances with people getting in front by pushing themselves in. And also many people would simply give their cards and money to someone in the queue already to pay for them. Hence the person at the counter was doing as fast as the other counters but had too many transactions per person to handle.

Why I am elaborating this story so much? This is part two of my previous blog and completing a job. You can complete this job of paying the EB bill in many ways.

1. By properly standing in the queue: Be Sincere

2. You can squeeze in and pay the bill and be efficient in comparison to the one who is following the option 1. : Be Efficient

3. You can find ways to avoid the queue altogether, for example pay someone to pay for you and stand for you or log on to your account online and pay without a sweat, Be Professional.

Be efficient sounds good in option 2 but it is not acceptable to someone who stands in the queue sincerely. But be Professional sounds the best option since you find better way to do a job and acceptable and sounds right as well.

This brings me to the concept of Professionalism and Sincerity.

Though Sincerity sounds right in any thing you do, it may not be the efficient approach in competing a job. That is why Professionalism is much needed to combine sincerity and efficiency. This is why professionals score more and earn more for a given job. But you have to find professionals who show professionalism as opposed to efficiency by short cuts just like our example.

It can be difficult for anyone to differentiate the people who can complete the job efficiently as opposed to completing professionally. The latter approach may sometimes appear to take longer and costlier. I see more people who can complete a job without professionalism but efficently. In fact lots of jobs completed are done efficiently.

The efficient methods of following shortcuts are good if the outcome is for one off use or has a definite end point. For example paying an EB bill as above. But where it really hurts if the outcome has long term use. For example a building or a bridge. Here Efficiency has to give way for Professionalism. Because if you do not follow professionalism, then the lack of quality would show in the long run.

But you have to remember that everyone of us is a professional in what we do if we show professionalism.


Regards Chockalingam

Our Trichy: Status of Sanitation and Hygeine, the Conundrum of Free Lunch and one that is paid for.

State Welfare Schemes and Government Welfare schemes are addressed to take off some of the inequalities in the population of the state or the nation. This to my understanding is that taking off some of the inequalities would give the underprivileged a head start in the race to achieving a reasonable or good standard of living.

If the population themselves are expected to achieve these comforts or essentials, it might take a very long time and that person may never see the benefit in his life time. This is why the State or the Government Free Benefits should continue.

Then the state or the Government has to decide which are the essentials and in what priority they should be given. Throughout the World , the countries have been doing this free benefits in different models. We will take Health Care for Example.

In UK, the Government vows to provide good health care for its population by beefing up the government hospitals with facilities, technical expertise and so on. Hence if you have an emergency then you feel safer in a Government Hospital even if you are the Prime Minister of that Country. You can walk in to any Government Hospital in UK expecting a good standard of health care for free funded by the Government.

Whereas in USA, the private providers take up the majority of health care provision just like our country. However the Government does not want the underprivileged to be left with a bad deal. They provide health insurance for those who cannot afford themselves. So you can walk in to any hospital who accepts Government health insurance to get your health care for free, funded by the government.

When the Government decides to give health Insurance for people who cannot afford themselves, or cannot buy health insurance for themselves and their loved ones, then it is commendable act. When it decides to give more free benefits like an item like a Television or a Fan or a Grinder which they can use in day to day life, one starts questioning them.

But I feel the issue is not the free item which is given at present. Because to me and you who is reading the blog, a fan may be a comfort which we can acquire easily but not to everyone. What is more important however is "what is not given which is more urgent to the needy".

I had the opportunity to see Trichy from a different point of view. Point of View is quite true in its meaning in that i observed Trichy by foot as opposed to going in a AC car.

Working in a hospital in India, I was alarmed in the number of Gram negative infections in my patients. These are not just wound infections after surgery for example, but in chest infections where these organisms are found.

Where do these bugs come from? From the community outside and the air we breathe in. If the sanitation is so bad outside and you are going to get infected with these bugs, then what is the benefit of all the comforts you acquire either by earning for it or by the State Benefits.

What is the point of having a toilet built for public use and charging for the same. If I am one of those underprivileged, I would rather go and do my duties outside for free and avoid paying to do so in a public toilet.

If you do not get my point by now, then this is it. There is an urgent need for addressing the Sanitation and the Hygeine for the environment as a whole to improve the quality of everyone's life. If the Government decides to build free and many public toilets for example, then it could be the best initiative ever.

Then I am told this had been done before and not used in the villages nor in the towns commonly. But having walked for nearly three hours in Trichy where the so called underprivileged live, i noticed only on public toilet.

What the Government should do is

1.to ensure that there are these facilities everywhere and make them free.

2. There should be clear directions in every part of the city and the villages.

3. These facilities should be brought under the vigilance of the Health Department. The contractors who are maintaining these can be independent, but their annual quota of money allocated can be linked to the health department vigilance report on their status.

4. The Government should then advertise the facilities so heavily that anyone not using such a free facility will be frowned upon.

If you then find a member of public not using these free facilities, available everywhere,maintained to high standard but funded by the government, then one can start fining the public to ensure that the sanitation standards do not fall.

You cannot blame the common man for passing urine outside in India yet until the above facilities are in place. Until then the India which we know lives as two halves.

One where people can afford and pay for it and maintain good standards and enjoy comforts they want. The second would be the one where people not only do not have the essentials and do not have a choice in spoiling the environment for the first half as well as themselves.

This is exactly the reason why the first half should worry about the second half and not just walk over them. The second half do not need the pity but essentials in life to be provided to them until they can move up in the social ladder.

The most essential of all is the Sanitation and Hygeine and the so called underprivileged people will find ways to earn the rest. So back to Health care Provision for free, I hope to go to any city or village and able to do our essential morning duties for free, funded by our Government.

or will it be a John Lennon Song Imagine Scenario! Time only can tell us, Oh No, We do not have time, Remember time gone is already time lost. Read my previous blog on time and money.

Regards

Chockalingam

Doing a job vs completing a job: concept of professionalism and sincerity and how money clouds both.

Doing a job is standard practice in almost all our life. Not doing a job is not uncommon in some employed areas. In other words, we do see some people who get paid but actually not doing the job they are meant to do. It can be upsetting to people who do work well and get paid the same money or salary.

But the above scenario is not as frustrating as when someone does not do the job to completeness. It is like trying to fix a broken hinge by a repair man. We do across some scenarios where someone comes to the job but finds that he does not have the necessary tools. he leaves the site without completing the job at hand saying that he would come another day to complete the job.

The above scenario happened at our house when we recently fitted a new air conditioner unit. When the unit was delivered and the installation team came to our house, the installation team asked me to get the electrical wiring sorted out and they will complete the job in one hour after the wiring is sorted. They had inspected the site of the fitting and marked where the holes had to be drilled.

We duly called our trusted electrician who finished the wiring straightaway and no sweats!. We called the AC team back again. They started making the hole, they realised that a more powerful drill is needed as the wall is too thick. We asked them to sort it out. Oops!! there is a problem. they do not know how to get a more powerful drill.

We asked them to contact their office. Oops they do not know either. Then we spent next two days making phone calls to our carpenter and other friends who have done AC installation in their house. At the end we called our electrician back again, he did the hole straightaway and no sweats!

But the AC installation team have wasted our time for good two days. Remember the time is our precious commodity if you have read my previous blog.

Now you begin to understand that doing a job is different to completing a job. But wait, not completing a job is not the worst thing and wastage of our time.

Because completing a job can be achieved with different methods.

Take the above domestic scenario for example. The electrician who helped us for the AC installation not only had to complete the hole which was started by the AC team, but also had to correct the errors the AC team had made when they attempted the job. Now we bring the concept of Professionalism and sincerity.

Please wait for my next blog when it all makes sense.