Hypothetical situation, thoughts?

HermioneG, BSN, RN · Feb 6, 2018

In order to be protected from legal liability (and, in my personal opinion, to practice with integrity) you must work within your scope of practice in the manner that you have been trained. In the hypothetical situation you presented, you are making a diagnosis and doing an invasive intervention that could potentially cause serious harm to the person if you are wrong, or do the intervention improperly.

"Potential complications of NT include cardiac tamponade, life-threatening bleeding due to pulmonary artery or intercostal vessel injury, nontherapeutic (i.e., ineffective) NT insertion, and nerve injury/neuralgia at the insertion site" (Complications of needle thoracostomy: A comprehensive clinical review).

Or, if the patient doesn't have a true tension pneumo and while inserting the needle you cause a laceration to the lung, the patient can develop an air embolus.

Additionally, it can be difficult to properly diagnose the condition without ultrasonography. One study I ready on the subject said that approximately 30% of patients who were treated for tension pneumo in the prehospital setting actually didn't have it. Also keep in mind that the signs/symptoms of tension pneumo are not always going to be textbook, and that given the mechanism of injury there can be significant comorbidities that could make the accurate diagnosis in the prehospital setting very difficult without the proper resources and training.

As far as your reference to the trachea:

"Late and unreliable signs: Increasing tension may include tracheal deviation (or tracheal "tugging") and jugular vein distension (JVD). Simple visual inspection is unreliable in detecting tracheal deviation. Bates' guide to physical examination recommends placing your fingers on either side of the trachea to determine if the distance between the trachea and the sternocleidomastoid muscle is equal bilaterally. Prehospital Trauma Life Support (PHTLS) indicates the trachea is bound to the cervical spine and fascia, and deviation would be detected lower, at the sternal notch" (Tension Pneumothorax | EMS Reference).

"In this case, providers would simply feel the deficiency of the trachea if it has shifted to one side. These authors also point out that JVD might not be present either. If tension pneumothorax results in decreased cardiac output with hypotension, it is not likely to cause JVD. Note that although tracheal deviation is rare, it is primarily a sign of tension pneumothorax. In contrast, JVD can be present in multiple conditions, such as cardiac tamponade, so it is not necessarily an obvious tension pneumothorax finding" (Tension Pneumothorax | EMS Reference)

The point of both of those quotes from the same article is to show you how detailed and specific diagnosing it can be.

Without extensive training I don't think it would be appropriate for a nurse do that on a patient. Additionally, I don't think its ethical to have the patient decide if they want you to do it or not by asking them to nod their head. You are the medical professional, you know the limits of your training and the patient may not or may not be in a position to make an informed and rational decision, especially while scared and in pain.

What would I do in this situation? I like the idea in the end of the article

"EMS providers should maintain good situational awareness and not fixate on one problem. If mechanism existed to create a tension pneumothorax, then other traumatic injuries may also be present. Thorough assessment and monitoring of the patient's condition is also essential. Look for other causes, injuries and co-morbidities" (Tension Pneumothorax | EMS Reference). I would do everything within my training and ability, and do everything in my power to get them to help. Anything outside of that seems to be reckless and you'd be putting them, as well as your license, at risk.

But, hey, thats just my opinion.

Here.I.Stand, BSN, RN · Feb 6, 2018

The extent of a nurse's "field training" is BLS, holding pressure, holding c-spines. There is absolutely no way in hades I would do an invasive procedure without training. Besides, I don't exactly carry sterile supplies with which to DO said procedures. Even if I was confident I wouldn't kill the pt -- which I am not.. again I'm unqualified -- what exactly could I do without appropriate supplies?

I'd call 911, hold pressure if blood gushing, hold c-spines, and be prepared to initiate BLS. Trained first responders will be on scene soon.

HermioneG, BSN, RN · Feb 6, 2018

Also, here's a great article on the topic of needle decompression that I want to put here to really drive my point home. In these "what would you do" situations, its important to look at the big picture. Diagnosis can be complicated and the procedure can be difficult and come with risks. There are other supportive interventions that we can do that are within our scope.

One study showed that only 60% of a sample of 25 emergency physicians were able to correctly identify the second intercostal space (which is where someone would do the needle decompression). At first thought one might say "oh, but if this patient was CLEARLY DYING to try is better than to not try." I don't necessarily agree with that because based on the situation we may have our adrenaline pumping and misunderstand just how bad the patient's status is. We also may be misunderstanding what we are seeing based on complicated co injuries and cause unintentional harm to the patient through our misunderstanding.

We have to see it as the serious business that it is:

"Rawlins et al.,[3] and Butler et al.,[2] described life-threatening injuries, including hemothoraces, that complicated the placement of NT. Management included postprocedural resuscitation and surgeries in two cases. However, surgery could not confirm which vascular structures were injured.[3] In another case,[2] a young woman who had a NT placement in the left anterior second intercostal space at midclavicular line was noted to have an immediate sanguineous output of >300 mL. She became hypotensive, requiring immediate fluid resuscitation. A portable chest radiograph showed no residual hemothorax or PTX, but a chest CT demonstrated a large pericardial effusion and fluid in the mediastinum with the catheter tip near the pulmonary artery. The patient was subsequently taken to the operating room, where a 3-mm perforation of the main pulmonary artery was noted in close proximity to the right ventricle.[2] Potential mechanism of major vascular injury has been outlined in Figure 4.

Riwoe and Poncia[25] reported a case of subclavian artery laceration following NT placement in a young female patient. Her initial chest radiography suggested a left tPTX, and a 14-G NT using the "catheter-over-needle" technique was used for decompression in the second intercostal space at the midclavicular line. Repeat radiograph showed resolution of the tPTX. She was then transferred to another facility and arrived with ongoing left-sided pleuritic chest pain, dyspnea, pallor, and hypotension of 95/59 mmHg. A second decompression was performed with a 20-Fr tube placed into approximately the third/fourth intercostal space in the midaxillary line, yielding 1,100 mL of blood. The patient was resuscitated with blood products and underwent video-assisted thoracoscopy that revealed hemorrhage from a perforated left subclavian artery. Some authors advocate the use of the mid-hemithorax line instead of the midclavicular line [Figure 3], as well as using the sternal notch as a point of reference for the intercostal level, in order to minimize the risk of major vascular injury.[25,32] Consequently, close attention to surface anatomy and key landmarks, as well as using the mid-hemithorax as opposed to mid-clavicular line may help mitigate the risk of iatrogenic bleeding. At times, a better alternative may be the use of the fifth midaxillary line as the NT placement site [Figure 1]."

(Complications of needle thoracostomy: A comprehensive clinical review)

Wuzzie · Feb 6, 2018

I AM trained to do needle thoracostomies and pigtail CT insertion and no way in heck would I do it. I no longer work in the job where I was trained to do them so my scope has changed and it is not within my current scope but even if it was I wouldn't do it. Point of clarification, one does not treat a pneumothorax by putting a "hole in a person's lung" which sort of supports why nurses who are not trained to do a certain procedure shouldn't even consider it no matter how many times they've seen it done. The risk is just too great. Especially when you think of the high complication rate for those who actually are trained. How many of you remember the old show "ER" when "Nurse Hathaway" was being held hostage in a drug store and "saved" a shooting victim by not only traching him with a pen but relieving a pneumothorax with a tampon applicator? Last time I watched that hot mess.

**NICU Guy, BSN, RN** · Feb 6, 2018

The odds of your hypothetical situation is extremely low. Even if you were trained to perform the procedure, you would do so outside your scope of practice. This situation would have to happen in some remote environment where EMS would take too long to get to the scene for the patient to survive. In an urban environment, EMS would arrive within 5 minutes and in the ER before you could even think about doing the procedure.

Meriwhen, ASN, BSN, MSN, RN · Feb 6, 2018

Good Samaritan Laws only protect you if you do things that are within the scope of your practice. If I were to render basic first aid, start an IV (look, there's a sterile IV start kit sitting in those bushes!), and do CPR, I'd be covered.

But if I decide that the patient needs an emergency trach and perform one (look, there's a sterile emergency trach kit sitting in the bushes next to the IV kit!) and something goes wrong--or right--with the patient as a result, I could face legal action.

Here.I.Stand, BSN, RN · Feb 6, 2018

@HermioneG -- thank you for posting supporting literature! I'm admittedly not one to spend lots of time reading lit, but this was very informative and cemented how I feel about it

Point of clarification, one does not treat a pneumothorax by putting a "hole in a person's lung" which sort of supports why nurses who are not trained to do a certain procedure shouldn't even consider it no matter how many times they've seen it done[/Quote]
I noticed that too, although my first thought was the OP is a student... I also wonder if this is a homework question, but I answered because I've seen some assert that RNs are first responders or similar.
At least I HOPE that RNs know the difference between the lung and the pleural space.

Wuzzie · Feb 7, 2018

At least I HOPE that RNs know the difference between the lung and the pleural space.

Yes one would hope. Sadly, I have experienced otherwise and it's positively frightening. They also think a scalp IV goes "directly into the baby's brain". Yikes.

Here.I.Stand, BSN, RN · Feb 7, 2018

They also think a scalp IV goes "directly into the baby's brain". Yikes.

EVD, IV... same thing. :sarcastic:

DayDreamin ER CRNP · Feb 7, 2018

Prime example of "Just because you can, doesn't mean you should."

I would only render care if there were no EMS on scene and the only thing I'd do is hold c-spine and render general first aid type of care. I would assist EMS if they indicated they needed it.

In most states, the Good Samaritan Acts will protect you - to a degree. As a trained healthcare worker, you could be held to a higher standard than what you are willing and able to provide and are definitely limited to your scope of practice. I can guarantee you, your facility will not back you should the fit hit the shan.

As @Guy in Babyland mentioned, the chances of ever having to do anything invasive is slim to none. And there's no chance in HELL that I'm even going to consider doing any type of procedure like that in the field.

Mavrick, BSN, RN · Feb 7, 2018

Good Samaritan Laws only protect you if you do things that are within the scope of your practice. If I were to render basic first aid, start an IV (look, there's a sterile IV start kit sitting in those bushes!), and do CPR, I'd be covered.
But if I decide that the patient needs an emergency trach and perform one (look, there's a sterile emergency trach kit sitting in the bushes next to the IV kit!) and something goes wrong--or right--with the patient as a result, I could face legal action.

This is my understanding of what the OP was asking. Doing anything outside your scope of practice is putting that practice at risk. If you insist on performing advanced procedures on the victim you would be purely at the mercy of the gratitude of the patient or good will of the surviving family.

Attempting to educate someone on the internet with detailed references to surgical procedures is pretty good use of sarcasm.

Obviously a nurse-lawyer would be best equipped to field the questions.