Date of Medical Observation
May  2008

A 48-year-old male was referred to me by my junior co-resident due to stab wound on his right chest. As I examined the patient, there was a pin-point puncture on his right chest. It was allegedly a stab wound from an ice pick. Though agitated which we thought was due to influence of alcohol, his vitals were normal. The x-ray plates revealed a pneumo-hemothorax on the right side while the left was normal. My junior co resident then did a chest tube thoracostomy. He was able to evacuate approximately  a hundred milliliters of blood. Afterwhich he sent the patient for post-CTT chest x-ray.

While in the x-ray room, the patient was restless and combative, the radiologic technologist had a hard time taking a single film from him. Then he started to show hunger for air as he breathe heavily.  They hurriedly transferred him to ER complex for immediate resuscitation.  I was surprised. I examined  the post ctt x-ray plates. The air was gone so was the blood inside the pleural space, the lungs were fully expanded yet this patient was drowning.

I stared at the plates wondering why it is happening.

Did we miss something?

The lungs were remarkably normal.

Seconds of silence made me figured out what we missed. The aortic knob was exaggeratedly widened as if it was shouting on me waiting to be noticed.

I went back to the patient. I auscultated his chest and there was no breath sound.  The heart beat was too slow. His Blood pressure was unperceivable.

As quickly as I could, I inserted a large bore IV catheter below the xiphoid and directed it toward his heart. To my expectation, I was able to aspirate blood. I tried to evacuate as much blood as I could as everybody continued to resuscitate him.

Another fifteen minutes, twenty, thirty minutes.

We failed. We lost him.

INSIGHT

n  Physical, Ethical, Psycho-social

n  Discovery, Stimulus, Re-inforcement

We could have saved him if we were able to recognize his cardiac injury early.

Distended neck veins, muffled heart sounds, hypotension this is the beck’s triad.

Yet more often done not, you would just notice this complete triad when the patient condition was deep down beyond resuscitation. Worse enough this triad will not present at all.

I can hardly recall a single patient who survived an occult pericardial tamponade which developed gradually. Recognition is always late.

Sustaining true and obvious cardiac injuries would be more fortunate since immediate thoracotomy could be done.

I guess what would be of utmost help is a high index of suspicion a surgeon must have in dealing with a direct chest wall injuries. We must consider a cardiac injury in all patients presenting with chest wall injuries until proven otherwise.

When viewing the x-ray plates. We should not focus on the lungs and pleura alone. Note the Mediastinal structures as well.

Lesson learned but I felt so sorry for this patient.

Yet this was too late.