Chest Tube Thoracostomy
Background:
Chest tube insertion is an essential procedural skill that must be mastered by practicing emergency and surgical providers. It is a lifesaving procedure indicated in cases of pneumothorax, hemothorax, chylothorax, empyema, esophageal/gastric rupture into the pleural space, and traumatic arrest. These critical patients require immediate decompression and evacuation of pleural space pathology. Therefore, chest tube insertion must be performed competently and expeditiously to prevent further morbidity and mortality. Performed improperly, chest tube placement can lead to ineffective decompression as well as life threatening visceral and vascular injury. Overall complications rates have been quoted up to 37%. Simulation offers a safe and effective method to master such procedural techniques. Unfortunately, many chest tube simulators are expensive or do not offer a realistic simulation experience. Therefore, we have designed an economical device that has a life-like feel, very similar to human skin and tissue.
This chest tube simulator uses a piece of pork belly that includes skin with underlying muscle and fascia. This tissue is placed over wooden strips and foam tape which are a proxy for human ribs and pleura. This chest wall anatomy allows the learner to locate landmarks, palpate intercostal spaces on real skin, and perform blunt dissection with a realistic "pop" of pleural tissue. Finally, since chest tube dislodgment is a common and unfortunate cause of morbidity and mortality, this chest wall design allows the learner to practice the essential and various techniques of securing the chest tube to real skin.
Supplies:
1. Sterilite 6 Qt (13 5/8" x 8 ¼" x 4 7/8") plastic storage container with lid purchased from Home Depot
2. ¾ "x 3/4" x 8' piece of pine purchased from Home Depot (PVC pipe is even better as it is easy to wash after each use)
3. Liquid nail adhesive purchased from Home Depot
4. 1 roll 3M microfoam tape purchased from Amazon.com (Alternate choice: duct tape from Home Depot)
5. 1 roll of stretch wrap purchased from Home Depot (3M Loban Surgical dressing is a costly but superior product available from amazon.com)
6. Pork Belly with skin still attached cut into 6 inch by 5 inch pieces about 1 inch thick, purchased from Ranch 99 Asian Market or local meat market
7. Clorox household bleach solution or disinfecting wipes for cleaning of reusable apparatus
8. Mannequin head and torso with blue surgical drapes (OPTIONAL)
Instructions:
1. Cut 2 inch by 6 inch rectangular hole in lid of plastic container
2. Cut the ¾ inch pine into 5 inch pieces with hand saw
3. Glue ribs (pine pieces or PVC pipe) to lid at an 80 degree angle leaving 3/4-1" spaces (for added strength, staple wooden strips at underside of lid and leave to dry overnight)
4. Apply 3M microfoam tape over top of ribs, dipping into the intercostal spaces
5. Place pork belly over top of ribs
6. Secure pork belly with stretch rap, applying generously in a spiral fashion from right to left along the length of the box and then right to left along the width of the box (Alternative: use 3M Loban surgical wrap to secure pork belly to ribs and box, if available)
7. Incise a rectangular window in the stretch wrap to expose pork skin
8. Secure apparatus adjacent to mannequin torso with tape
9. Cover apparatus with blue drapes
To place Chest Tube:
1. Locate 5th interspace. Make a 1.5-2 cm incision parallel to the rib
2. Insert curved Kelly forceps into wound and perform blunt dissection. Slide over rib to the next interspace and then puncture pleural lining
3. After digital palpation, insert 36F chest tube with assistance of curved Kelly clamp
4. Suture wound and secure chest tube
5. At completion of task, discard the pork belly and disinfect trainer with liquid bleach or disinfection wipes for reuse, if desired
Chest Tube Publication in the Journal of Education and Teaching EM