Description of Event or Problem · 0
THIS IS A 67-YEAR-OLD MALE WITH A PAST MEDICAL HISTORY OF COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) INITIALLY PRESENTED TO THE ED WITH WORSENING SHORTNESS OF BREATH. IMAGING NOTED LARGE RIGHT PNEUMOTHORAX. HE UNDERWENT CHEST TUBE PLACEMENT IN THE ED. PULMONARY WAS CONSULTED FOR FURTHER EVALUATION. A PHYSICIAN WAS CALLED EMERGENTLY TO BEDSIDE BY THE HOSPITALIST TEAM AS THE PATIENT WAS COMPLAINING OF SHORTNESS OF BREATH, NECK SWELLING, DIFFICULTY WITH BREATHING, AND NOTED TO HAVE EXTENSIVE SUBCUTANEOUS EMPHYSEMA AROUND THE NECK. AN RRT (REGISTERED RESPIRATORY THERAPIST) HAD BEEN CALLED DUE TO RESPIRATORY DISTRESS. HE WAS STARTED ON A NON-REBREATHER MASK WITH SOME RELIEF; A REPEAT CHEST X-RAY WAS OBTAINED WHICH SHOWED NO SIGNIFICANT INTERVAL CHANGE. ON ASSESSMENT, THERE WAS STILL SOME AIR-LEAK IN THE CHEST TUBE, HOWEVER, THE CHEST TUBE STYLETTE APPEAR TO STILL BE IN PLACE, IT WAS REMOVED AND REATTACHED THE CHEST TUBE TO THE PLEUR-EVAC WITH INCREASED AIR LEAK, THE PATIENT STATED THAT HE WAS STARTING TO FEEL BETTER. STAT CT OF THE CHEST WAS THEN OBTAINED, IT SHOWED THE RIGHT PLEURAL PIGTAIL CATHETER IN PLACE, WITH A SMALL RIGHT APICAL PNEUMOTHORAX, EXTENSIVE ASSOCIATED PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA IN THE BASE OF THE NECK AND CHEST WALL. IN REVIEW OF THE DEVICES, THE STRAIGHTENER WAS LEFT IN THE PIGTAIL CATHETER AND ALLOWED CONNECTION TO THE SUCTION DUE TO ITS CONFIGURATION IF THE STRAIGHTENER WAS REDESIGNED THAT MAKES THE CONNECTION UNACCEPTABLE THIS WOULD DECREASE THE LIKELIHOOD OF ERROR. WE HAVE REACHED OUT TO THE MANUFACTURE TO DISCUSS POTENTIAL REDESIGN, IF POSSIBLE. LARGE RIGHT PNEUMOTHORAX.