VOTW: "Eye-Yahh!"

This week’s VOTW is thanks to Drs. Jennie Xu and Leily Naraghi!

HPI: 56 yo male with PMH of HTN presenting for sudden near complete vision loss in his right eye since 1pm yesterday.

Review of POCUS eye anatomy

Image/Video 1: Retinal detachment - you can differentiate this from vitreous hemorrhage because retinal detachments are typically thicker and are tethered to the optic nerve posteriorly.

Image/Video 2: “Washing machine sign” is concerning for vitreous hemorrhage

There are ways to figure out if a retinal detachment is “mac-on” or “mac-off”. The macula is temporal to the optic nerve in each eye. “Mac-on” retinal detachments are true ophthalmological emergencies and need to go to the OR emergently to have the retinal reattached and save their vision. It's hard to be sure though so if you see a retinal detachment, consult ophthalmology.

Conclusion: Patient was transferred to SUNY Downstate for ophthalmological repair of partial retinal detachment.

POTD: Where do I go?

Today’s POTD is going to be about where to find certain locations in the hospital. Some of these places might not be as relevant most of the time but it’s helpful to know on the very busy days to expedite patient care or inpatient rotations. It’s also helpful to know where the clinics we send our patients to most often are (like dental and ophtho) so that we can give proper instructions for follow-up. I know there’s no map to help orient yourself but hopefully it’s a little helpful. :) 

Dental Clinic - 4802 10th avenue, 2nd floor

The same building as our conferences, also on the 2nd floor but just past Schrieber auditorium

Ophtho clinic 902 49th street

On 9th ave at the corner of 49th street

Blood bank - 4802 10th avenue, 3rd floor → Once you exit the stairs, make a left at the end of the hallway

The same building that we have conference, on the 3rd floor; easiest way to access it is by going outside the hospital (even though there is a way of going through the hospital but can be confusing / takes longer)

This is helpful for off-service rotations where they need emergent blood transported and sometimes no one else is available

Lab - 4th floor → use elevators between resident’s lounge and kitchen

this one is mostly really important to drop off CSF studies so that there’s no delay in processing 

Go through this door, down the corridor

Ultrasound - 3rd floor → use elevators (set of 4) near resident’s lounge 

Operating room - 4th floor → use elevators that are just past KRB

Gives an idea of where to go for the anesthesia rotation 

MICU - 7th floor

Use the elevators past KRB

SICU - 8th floor

Use the elevators past KRB

PICU - 6th floor

Use the elevators between the resident’s lounge and kitchen 

CCU - 2nd floor

Use the elevators between the resident’s lounge and kitchen

POTD: "Leak" out for those chest tubes!

Today we’re going to talk about what to do when it seems like the chest tube is not functioning properly. (Everything here applies to any type of chest tube placed, not just large bore).

The biggest thing to take away from this is how to manage an air leak and only clamp the tubing when necessary and for a few seconds (not routinely and not for extended periods otherwise it can cause a tension pneumothorax).

Let’s start by talking about how you can tell the chest tube is functioning properly (aside from drainage and confirmed CXR). 

You should see tidaling occur (as seen in graphic below) which demonstrates the water in the chamber moving according to a patient’s respirations. 

There are multiple things that can indicate the chest tube is not working appropriately so let’s talk about what you would see and how to approach some of them.

There may be an air leak which you can find by looking for constant or intermittent bubbling in the water-seal chamber. (it is common to have some bubbling upon initial placement of the chest tube but watch for constant and a large amount of bubbling). 

To find the source of the air leak, clamp the chest tube (only for a few seconds) starting from where it enters the chest and moving toward the pleur-evac. If the bubbling stops when you clamp the chest tube where it enters the chest, the problem is more likely internal and the chest tube might need to be completely replaced. 

If the bubbling stops when any site more distal, along the tubing, is clamped, the tubing might need to be replaced. 

If the bubbling stops close to where the tube enters the pleur-evac, the chamber itself might need to be replaced. 

Subcutaneous emphysema at the site of the chest tube dressing could indicate a worsening air leak within the chest cavity and potentially even development of a tension pneumothorax so immediately obtain an x-ray to assess progression. 

Drainage may stop → check for any kinks in the tubing and reposition the patient so they are upright. Always make sure the pleur-evac is below the level of the patient to allow proper drainage.

If the tubing accidentally gets disconnected, clamp the chest tube at the site closest to the dressing only briefly until the tubing can be replaced OR place the distal end of the chest tube in a bottle of sterile water so everything can continue draining until the equipment is replaced. 

The list of things that can go wrong with a chest tube is never-ending but I wanted to mention some of the more common ones we may see while the patient is still in our ER. 

Here’s another video to help with visualization (more helpful around 10:40 mark): https://www.youtube.com/watch?v=YOpzcWc3yrw&t=1139s

~~

https://www.ncbi.nlm.nih.gov/books/NBK594490/#:~:text=If%20drainage%20suddenly%20stops%20in,blockage%20in%20a%20dependent%20loop%3A&text=Assess%20the%20drainage%20system%20and%20the%20client.&text=Inspect%20for%20kinks%20and%20straighten,connection%20with%20the%20collection%20device.

https://opentextbc.ca/clinicalskills/chapter/10-7-chest-drainage-systems/

https://www.perplexity.ai/search/when-is-it-191OyTWbRqSV3.KHzmoORg#0