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Wed, 1 May 2002 01:15:29 +0100

I haven't seen trocars used (thankfully) since I was at medical school.
However at medical school I saw one patient die from trocar in the pulmonary
vein (very traumatic, unpleasant death too) and also one trocar in the
bladder! (patient in chronic retention).

Even without the trocar chest drains seem to be put in very badly.  I think
this is partly because they are perceived as a simple procedure that anyone
can do having had one go on some dead or dying sheep on an ATLS course.
Pleural drainage needs careful mentoring and training if one is to avoid the
(quite common otherwise) complications including intercostal haemorrhage,
inadequate drainage, tube trying to erode into the oesophagus etc etc.  And
all this with blunt dissection, never mind the trocar.  As you say, the more
you look, the more you find. Do the audit.

Karim

-----Original Message-----
From: trauma-list-admin@trauma.org
[mailto:trauma-list-admin@trauma.org]On Behalf Of Cotton, Chris (SAAS)
Sent: 30 April 2002 12:20
To: 'trauma-list@trauma.org'; 'KMATTOX@AOL.COM'
Cc: 'crippen+@pitt.edu'
Subject: (no subject)

Ken,
         you put this response below to the ccm-l website and i thought it
could be a good thread to discuss our recent topic of cardiac arrest
management in trauma. David Crippen, i hope you don't mind me borrowing it.

>>> <KMATTOX@AOL.COM> 04/25/02 08:48PM >>>
"Trocar" chest tubes should be taken off the market as a dangerous device!

Should the kinds of injuries which are in the literature, seen in EVERY
hospital that looks for them, and produced by anyone who uses trocar chest
tubes, regardless if they are surgeons, thoracic surgeons, paramedics,
emergency physicians, intensivists, pediatricians, traumatologists,
pulmonologists, or anyone else.   If one has not seen iatrogenic injuries,
including fatal air embolism, lung perforations, fatal hemorrhage, and
malplacement into organs of the chest, abdomen, neck, and mediastinum in
their personal or hospital practice where trocar chest tubes are purchased,
they simply have not looked.  One does not see what one does not look for.

Since the resurrection of this discussion, I have contacted FDA that this
dangerous device should be removed from manufacture and distribution in
interstate commerce because of its iatrogenic injury potential.

Those who used the "absolute" phrases regarding trocar chest tubes simple
were not emphatic enough.  I would strongly recommend that all who read this

web site to go to their hospital stores and should any trocar chest tubes be

found they should remove them from the shelves, take them to the desk of the
h
ospital administrator or chief of staff and request that the hospital send
them back immediately.

As an emergency physician, as a thoracic surgeon, as a traumatologist, as an

intensivist and as one who reads some of the literature, contributes to some

of it, I know of NO PLACE where the informed and caring physician would EVER

use or recommend TROCAR chest tubes.   They should be relegated to the
curiosity section of the medical museum.    I have seen either in the
literature, court room, autopsy room, or operating room a puncture of the
following organs by trocar chest tubes, most often by surgeons and thoracic
surgeons who think they are immune from such iatrogenia because they know
the
anatomy:  liver, colon, spleen, kidney, pancreas, stomach, diaphragm, heart,

lung, thoracic aorta, abdominal aorta, inferior vena cava, esophagus,
trachea, thoracic duct. and others.

Please, because, someday I may require health care in your hospital, and
because someone on duty may in their judgment think that I need a chest
tube,
please, PLEASE remove all trocar chest tubes from your hospital, so that the

rare uninformed physician does not have the opportunity to stab me.

PS.  The trocars work very nicely on the barbecue pit.

k

------------------------------

Ok Ken ... you're sort of convincing me here - but what about a 12G
dwellcaths through the 2nd intercostal space, mid clavicular line in an
arrest patient due to suspected tension pneumothorax, or infact any trama
involving the chest that ends up in an arrest? ... ideal management would
NOT involve this? ... Ever? I'm looking for your guideance here - not
criticisms - i am starting to recognise that behind your, at times abrupt
manner, is a very swithched on man, so please explain yourself to me nicely;
that way i'm more likely to take the time to be convinced by your arguments,
coz it's a procedure that i still perform occasionally, when my clinical
judgement leads me to suspect that it may have some benefit. If you can help
me make the right decisions that are backed by reasonable argument and
evidence, you'll change my practise...and that's a good thing for me because
i'll pass that on to others. I know you'll think that is a good thing -
disseminating good information. That is why we are all here - to share
experience so others can learn and patients can benefit.

...and if you've got time, please give me your take again on volume
resuscitation as it sits with you and the rationale for your stance - i'm
interested to hear what you (and others) have to say.

Regards,
Chris Cotton,
IC Paramedic
South Australia

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