crepitus

[ORNurseAngie]

Had a patient a couple weeks ago, that had a mediastinotomy (sp?). Anyway postop should have went to the surg floor instead b/c of patients request was allowed to come back to our med/surg floor. Patient was okay immediatly postop vitals normal, dressing c/d/i, no s/s of distress, etc. Approximatly an hour post op "I noticed her face swelling and neck and increasing by the minute. I paged the surgeon who came to see the patient. He said, "it's just subQ emphysema, sometimes expected with this type of procedure." "I could insert a chest tube to drain the air but then I would just be treating the nervous nurses." (I was not happy about this comment). While we were in the room her eye was swelling up right before our eyes. Then the surgeon ordered a stat port cxray, which reveled a pneumothorax. One was done in recovery room which did not show a pneumo, so it happened sometime in the time between. Next thing I know they are inserting a chest tube at the bedside. By this time I was fuming about the "nervous nurses" comment. Was wondering if anyone had any experience with this type of thing? I work on a med/surg floor, but it is mostly med. We have a seperate surg floor where most of these patients go post op. Anyway would appreciate any feedback Thanks.

[RN28MD]

When you day type of thing, what do you mean? the pneumothorax? subQ emphysema? or the sarcastic MD?

[oMerMero]

You everything you could do. You noticed a change and notified the doctor right away. The surgeon was out of line, I wouldn't let it bother you.

[CodeBlack]

Good job recognizing the change of condition.

[Daytonite, BSN, RN]

yes. i've seen this subcutaneous crepitus happen a couple of times related to either central line or chest tube insertions. because it is air leaking from the pneumothorax or the chest tube into the subcutaneous tissues it tends to rise (air rises), so it goes first to the shoulders and then up to the neck and head. it depends on how large the rupture is that is allowing the air to escape that determines how much of this subcutaneous emphysema you will see. they will only insert a chest tube or readjust it if the air leak is substantial. in the case of your patient, the air building up in the tissues would probably have eventually interfered with some of her vital functions so the chest tube had to be placed. it would have been the only way to stop the swelling due to the air leakage. pneumothoraxes are not always visible on a first look cxr. sometimes they develop slowly as the patient breathes and coughs causing the rupture to open a little more allowing more air to escape.

i'm sure the physician probably regretted what he said earlier ("i could insert a chest tube to drain the air but then i would just be treating the nervous nurses.") the minute he learned the results of the stat cxr. this physician may interact much differently with you in the future knowing that you covered his rear end. keep focused here. your first priority was the patient and you performed correctly as an advocate for the patient. the physician's comment was unfair and came out of his own background of experience and insecurities. that is not your fault so don't play the game of getting his demons mixed up with yours. take pride in that you made a good nursing call. move on. we all drop little verbal bombs that we wish we could instantly take back the moment we've uttered them. it's the bigger person that apologizes for them, but the damage of the comment is still done and that can't be taken back.