Commentary: A conservative management plan from a place where barracuda are rare

BMJ 1996; 313 doi: (Published 21 December 1996) Cite this as: BMJ 1996;313:1618
  1. John Rees, consultant chest physiciana
  1. a Guy's Hospital, London SE1 9RT

    The general availability of chest x ray examinations has prompted some clinicians to diminish the importance of physical examination of the chest. Faced with a barracuda wound to the chest in a remote part of the Solomon Islands there is nothing else to fall back on, and percussion, tactile vocal fremitus, and breath sounds resume their true importance. Dr Berger had to advise at the end of a telephone line before managing to reach the patient. It was then that the main dilemma arose: was it to be the canoe or the aeroplane?

    The canoe was chosen for the 60 mile journey, but I am sure that was the wrong choice. Five hours in rough seas in a canoe are not the usual treatment for pneumothorax. If something had gone wrong it would have been much more difficult to deal with it in a canoe than an aeroplane and the travel time would have been much longer. Therefore, the justification for the canoe must be the risk of complications during an aeroplane flight.

    Commercial passenger aircraft are pressurised to around 2200 to 2500 metres. Atmospheric pressure halves by 5500 metres. At 2500 metres, air in an expansible space will increase in size by around 35%. This might cause respiratory problems or a fall in cardiac output with a large pneumothorax but is unlikely to have much effect with a small pneumothorax. Potential problems come from cysts or bullae which have poor communication links with the lung and which might rupture with the pressure change across the wall. Even then most such air spaces have time constants which allow equilibration during the time of an aircraft's ascent. In this case flight would have been in a light aircraft over the sea and could have been at 1000 feet or so, where there would not have been a significant change in pressure. The best plan would have been an aeroplane transfer at low altitude, with a cannula, syringe, and three way tap at the ready to deal with any deterioration.

    When the pneumothorax was a little bigger and he was short of breath initial treatment could have been aspiration rather than insertion of a chest drain.1 This would have been the equipment to use in the first place at the Seghe clinic rather than consider putting in a drain blindly without an x ray examination.

    This case illustrates the ingenuity needed to practise medicine in isolated areas. A less exciting management plan might have achieved the same successful outcome more safely, but this comment is written from London, where the numbers of barrucada wounds and canoe evacuations are not high.


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