Steve

This topic appeared in a string of emails in Sept 1996 on the list, and 
several members admitted to conservative management then ! There are too 
many messages to copy, but this was the text of one:

<<Perfectly reasonable strategy - but better left for departments where 
there is a stable group of SpR's who give each other a proper handover at 
shift's end !!

My first intro to conservative management was as an orthopaedic SHO when I 
witnessed my consultant arguing nose-to-nose with a cardiothoracic SR about 
whether a 2 year old girl with a # humerus and a small PTX with surgical 
emphysema needed a drain. The consultant won, and she resolved within 36 
hours under the caring eyes of the paed ward staff . I always find it 
amazing how quickly children bounce back to normal activities, even with 
appalling injuries !

BTW, what does the list think about the practice of aspirating small 
spontaneous pneumothoraces ?  This practice/fad seems endemic amongst 
physicians in Hong Kong but I think it's unnecessary in most cases. I've 
treated dozens of these conservatively with careful advice to the patient on 
activity and when to seek further help, and they have all resolved by 1-2 
weeks. Anyone had their fingers burned by doing similar ?

Rob Cocks
Prof. & Director
A&E Medicine
Prince of Wales Hospital
Hong Kong
 ----------
From: acad-ae-med-request
To: acadae messages
Subject: conservative tx of traumatic chest trauma
Date: Tuesday, September 10, 1996 11:03AM

Just a quick request of the lists views.

Case: 55 year old fit and well male falls 4 feet of a ladder onto the right
side of the chest. Presents to A+E with right sided chest pain, decreased
chest expansion and decreased air entry on that side. However, he is
generally well seen by SHO in A+E and gets an erect AP X-ray.

The film is of good quality and shows a fracture of the 4th rib. There is a
small (5cm) area of surgical emphysema seen on the chest film laterally
which is just palpable clinically. There is also blunting of the
costophrenic angle - presumably blood. There is no radiographic evidence of
pneumothorax (though there must be one).

He is going to be admitted for observation anyway. The question is should
you put a formal chest drain in this man?? We did not. The decision we made
has been criticised by some of our collegues.

Simon Carley
Anaesthetics / Intensive Care
Stepping Hill Hospital
Stockport
England
[log in to unmask]
 ----------
From: acad-ae-med-request
To: [log in to unmask]
Subject: RE: traumatic pneumothoraces
Date: Wednesday, February 03, 1999 6:12PM

Simon,

here's the refs

"Traumatic pneumothorax: is a chest drain always necessary? " Johnson,G, J
Accid Emerg Med 1996, 13, 173-174.
"Traumatic Pnemothorax: a scheme for rapid patient turnover" Knottenbelt
J.D. Injury 1990 21, 77-80.

Surely someone on this list is already managing these conservatively? We
plan to start this but would like to hear from those already doing it.This
is the principal value of the list surely - sharing knowledge.

Steve Meek

> ----------
> From:         Simon Carley[SMTP:[log in to unmask]]
> Sent:         02 February 1999 16:45
> To:   [log in to unmask]
> Subject:      Re: traumatic pneumothoraces
>
> Could you post the references (or better still the abstracts)???
>
> Thanks,
>
> Simon
>
> Simon Carley
> SpR in Emergency Medicine
> Hope Hospital
> Salford
> England
> [log in to unmask]
> -----Original Message-----
> From: Meek, Steve <[log in to unmask]>
> To: [log in to unmask] <[log in to unmask]>
> Date: 02 February 1999 14:43
> Subject: traumatic pneumothoraces
>
>
> >Hello
> >
> >Do any list members treat small traumatic pneumothoraces expectantly?
> >(observe, no chest drain). Graham Johnson and John Knottenbelt's papers
> >suggest this is safe but what is missing is how long to observe for - 12
> >hours? The latter's paper from Cape Town suggests chest drains can be
> >removed as soon as bubbling stops and x ray shows the lung is inflated...
> >any comments? Clearly an obs ward and 24 hour on site middle grade cover
> are
> >prerequisites
> >
> >Steve Meek
> >
>


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