Projects by Department | Proposal Guidelines | LTLC Homepage

FINAL REPORT ON 'ALUM EXPERT OF THE WEEK'

Progress Towards Objectives The two specific aims described in the proposal have been accomplished: 1. The students did learn a great deal of clinical applications of physiological concepts from our "alum experts" via e-mail. As a consequence, they also gained a better understanding of many basic concepts in cardiovascular/pulmonary physiology. 2. the program did provide an opportunity for current students who are interested in medicine to communicate with alums who are in the field. In addition, the chemistry between the two groups was so good that not only did the current students feel the "loving care" of the "big brothers" and "big sisters", the alums also gained a sense of satisfaction in helping and teaching the younger "siblings". Primary Activities Including Challenges Since the class had only seven students, I only had to recruit seven "alum experts" although I tried very hard to contact twelve alums who had worked with me on research projects when they were seniors. I was lucky with a few, but the others were extremely hard to contact. I was calling some of them using different phone numbers provided by the alumni office almost till the end of the semester. A few were recruited just in time for the particular weeks. Among the seven "alum experts" three were extremely thorough in answering the questions. I am sure the others just happened to be extremely busy when they were supposed to be the "alum experts" The short class discussion sessions after collecting all the messages from each "alum expert" also proved to be very helpful. Next time when I repeat this program, I will definitely recruit the "alum experts" before the semester starts. An Example of One "Alum Expert of the Week" Hi Jonathan, my name is Aileen Maria and I am a senior here at Wheaton. I'm taking Professor Tong's advanced physiology class and as Prof. Tong already told you I have a couple of questions about a recent "ER" episode. A patient was brought in from a chopper crash. As he is in the ER he then gets tension pneumo. and they plan for a chest tube. The Dr. asks for a 36-French and 20cc's of Xylocaine. I found that the 36-French -had to do with something measured on a French scale (1mm=3fr) and thought that maybe they were referring to the tube and its diameter, but I'm not really sure. I also found that Xylocaine is a local anesthetic (hence the ending -caine) and I'm guessing that it is used for the chest tube procedure. How is the chest tube done, also in relationship with the 36-French (tube?) 20cc's of Xylocaine used (seems like a lot of anesthetic)? Where is it applied? Another question I have has to do with the tension pneumo. I learned that this occurs due to presence of air in the pleural cavity usually occurring because of a puncture in the thoracic cavity or trauma to the chest. This patient did not have any puncture wounds and may have had some trauma in this area. How can air get into the cavity without a puncture? If there is anything else that you can tell us about this patient please feel free to do so. Anything else that is relevant to a cardiac and pulmonary situation that did not come up in the episode? You will probably be receiving some other questions that other students in the class may have towards the end of the week. I'm sure that you must be very busy with school, so feel free to answer when you are able to! I myself will be going to graduate school next fall, to the New England College of Optometry and hopefully become an eye doctor. Thank you for taking time in helping us learn more about this! We really appreciate it! Below I have included a copy of the case that I presented in class. Aileen Maria Case#2 SCENARIO: A man, who was in a helicopter crash, was bought in with his crew who were critically injured and had severe burns. He had a fractured ankle and did not seem to have as many complications as his crew members. He and Dr. Greene's father started talking to each other when, all of a sudden, Dr. Greene's father noticed that the patient stopped talking. Dr. Greene checked to see if the patient was still breathing and checked his pulse; there was no carotid pulse. He immediately called the medical staff to bag the patient and started pumping his chest (CPR). The patient was crashing and was said to have tension pneumo. A 14-gauge is inserted in the upper chest area. Afterwards, they prepared for a chest tube, and they used a 36-French and 20cc's of Xylocaine. SYMPTOMS: carotid pulse- pulse of two arteries on both sides of the neck which supply blood to the head (3) crashing- going under cardiac arrest (1) tension pneumo- (pneumothorax) damage to the lungs due to major trauma which has caused the lung to collapse. This is due to presence of air in the pleural cavity. As the pressure builds up within the cavity, the structures of the mediastinum (i.e. trachea) are dislocated to the opposite side. The air in the chest also constrains the blood circulation, not allowing the blood to be pumped (1,2) TREATMENTS: Bag (him)- an ambu-bag is placed over the person's mouth and nose in order to simulate respiration (goes along with pumping of the chest) (1) 14-gauge- a specific size hypodermic needle, which, in this case, was inserted in the upper chest area allowing the tension of air to be released and for the trachea and other structures to move back to the middle (3) chest tube- a tube which is inserted into the chest cavity and into the pleura by making an incision (in this case specified at 5th intercostal space, mid-axillary line). This tube re-inflates the collapsed lung and gets rid of any blood and air from the chest (1) 36-French- ?the size of the chest tube. Size is on French scale, in which 1mm=3fr (therefore, a 12mm tube) (3) Xylocaine- a local anesthetic agent which is administered by injection (4) SOURCES: 1. The Medicine of ER 2. The Oxford Medical Companion 3. Stedman's Medical Dictionary 4. Physician's Desk Reference 1997 Hello Ms. Maria, I wish you the best of luck in grad school at my dad's alma mater. I know many of your future profs and almost went there myself. I am not sure exactly how this works but I will address your questions first then try to add some (hopefully helpful) tidbits of info. If you have more questions or want more info just write back and I will be happy to help...sound good? Ok...here we go. 1. You were correct..36 Fr is just a tube measurement. French measurement is used for chest tubes, urinary catheters and other types of tubes. Gauge is also a measurement that is used for needles. It is a system set up to standardize the size of the instrument. 2. Xylocane is a local anesthetic (lidocaine HCl) which comes in a variety of strengths in percent. ie: 0.5%, 1%, 1.5%, and 2%. This is used as a local anesthetic. In this case it is used to numb the skin and prevent the patient from feeling the incision for the tube and prevent the patient from moving while the tube is being placed. It comes as an injection or with epinephrine (also in varying amount) having this in the mix is very useful when doing some procedures. The epi causes local vasoconstriction which makes a wound less bloody when suturing. (Before giving any of these always ask for allergies!!!!!) Also whenever you give an injection you should aspirate your needle first..why? To make sure that you are not is blood vessel...b/ you dont want to send it through their circulation. Also beware of using epi on fingers, nose, ears, toes, and other extremities that would be in danger of having there already limited blood supply compromised. More than enough about xylocaine! eh? 3. Where did the air come from if no puncture? Good question. It comes from his breathing. The air he is inhaling is not finding an intact lung but rather a lung that been traumatized. Instead of breathing in and then out...his lung takes air in...some goes out but from the damaged lung. A space has formed and traps the air...increasing the pressure with each subsequent breath. Do you remember your anatomy? Lung pleura.....easiest way to understand this is...Have you ever stuck your hand through a blown up balloon? you stick you hand in it and you look at it from the other side? Maybe I am the only nut! hopefully you have done this...now your hand is the lung the balloon is the pleura....while your hand is in the balloon there is no space....but there is what we call a potential space. Under normal conditions the pleura stayed against the lung...but if air is released from the lung (in our case from you hand) this pleura would move away as it is filling with air. SO !! what!? This is bad b/ it compromises the space that the lung needs to fill up. At last ...this is where you come in with you tube! You place the tube in this space to release that FREE air....once this is done the lung has its space back and is able to reinflate! If this is not clear let me know! This potential space can have air(pneumothorax) or blood(hemothorax) It is even possible for this to happen with no trauma! It is called a spontaneous pneumothorax and results from the rupture of what is called a bleb or a weakened part of the lung parenchyma. . There are many different types and classes. 4. Hopefully you now understand why a patient can...crash. The pressure that takes the lungs space is also great enough to cause a mediastinal shift...the trachea and great vessels are in the mediastinum. Shifting these very important structures can cause pressure on the vessels and compromise blood flow to the brain and other organs. it is important to release this pressure with the tube.(you can actually hear the air come out when this is placed in...you can also see it b/ they connect the tube to a vacuum setup that has water in it....you get to see the bubbles! And the patient lives to fly another day! Hopefully that is what you were looking for...if not let me know and I will re-explain or elaborate. Since you told me about you I am probable supposed to say something about me. I was in Dr. Tongs phys and cell phys I was also his lab assistant for phys and helped with the computer part of his angiogenesis work....I worked with Eric Frizzel and Alan L....you might have heard from Eric already. I was a bio major, did research for one yr. after Wheaton and then went to med school in ME....UNECOM...university of New England College of Osteopathic Medicine. Like Eric I will also be in the Army when I am done. I am not sure what type of med I want but will eventually figure that out. Good luck with everything....do you know what the old name of New England College of Optometry was? jonathan Dear Jonathan, First of all I want to thank you for your quick and detailed response! All the information helped a great deal! Some students in the class have a few questions concerning the ER case and would appreciate it if you could answer what you could... 1. What might cause a spontaneous pneumothorax? Is it associated with any particular disorder or disease? 2. What signs are characteristic of pneumo.? How is it typically diagnosed? 3. What criteria are typically used to evaluate the type of anesthetic that should be used in a given situation? 4. Why is the 5th intercostal space, mid axillary line specified for incision? 5. Why do they give the patient the painkiller (i.e. xylocaine) when they are unconscious? Do they usually give unconscious patients painkillers? Because it seems that if the patient is unconscious they would need an anesthetic...or do they give it to the patient to prevent them from feeling pain when they come out? Well, there they are..these are the last set of questions that you will be receiving...again, feel free to answer when you could. And thank you for helping us better understand this case!! Aileen P.S. The old name of NEWENCo used to be Massachusetts School of Optometry. All right, good questions. Let me first say it is in the low 70's here and the palm trees are blowing in the light breeze...anyway lets get to the questions. 1. Causes of spontaneous pneumo? here is the quote from principles of surgery handbook... "spontaneous pneumothorax most commonly results from rupture of a pulmonary bleb or bullae and occurs in young males without significant pulmonary disease. The incidence of recurrence increases after each episode....." From other readings I recall a higher incidence in patients with a disease called Maphans or Marfans but I am not positive. Pneumothorax can also occur in patients with ARDS adult respiratory distress syndrome who are on a ventilator(from the pressures) This is important but it is not a spontaneous so I wont go any further. 2. Signs and symptoms? this depends on the severity and percentage of lung collapsed.... shortness of breath, chest pain, agitation, hypoxemia, hypotension(if a tension pneumo) lab values would show an ABG (arterial blood gas) with a decreased PO2 . The CXR (chest x-ray) should also show an area of air where the lung used to be. These are sometimes hard to see but you can tell b/ there are no lung markings(vessels or tissue) in the air space. Also, on physical evaluation it should become apparent when there are no breath sounds in an area. There should also be a difference in resonance when you precuss the patients back. This is a technique where you tap on the back and listen for different pitches of sound which will be produced. (the quick answer to this question would be..1. the clinical history and physical exam 2. a chest x-ray 3. This can be answered with question five. There are not that many choices for topical anesthesia. So many have there own personal favorites unless it is in those certain areas we talked about before where there you don't use epi in the anesthesia. Why use it on an unconscious patient? There are levels of unconscious and pain is one of the senses that hangs on. This is why you see EMT do things like sternum rubs and pinch tests to people who are down...this is to tell how out they really are. Using the anesthesia guarantees they wont feel it. Plus a patient has a dramatic response when the pneumo is released ie: they are back to the real world very fast!! If it were you or me I would want the anesthesia before I got this done....oops maybe I did not explain this well enough. The anesthesia is injected superficially into the skin first and then it is injected deeper into the intercostal musculature and pleura. This is a very painful place to b cut!!! And the procedure is somewhat brutal as a large clamp is used to burrow through the incision and tunnel through the pleura over the rib. (over the rib because the neuro vascular bundles run under the ribs and you DONT want to hit these!) 4. Why fifth intercostal? It avoids the breasts of women and the pectoralis musculature of athletic men. But this is not a hard and fast number...it can be the sixth. I have also seen a doctor insert a much smaller tube in the anterior aspect of a young mans chest to relieve a "spontaneous pneumo" (I used quotes b/ it was not so spont...as his brother punched him in the chest many times..they were just playing around) Well I hope that answers your questions. If you need anything more please feel free to ask... Sorry for the delayed response...good luck with your classes and with optometry school. Tell Dr. Tong. I said hello and hopefully I will get a chance to stop by on my way home. Take care jonathan

Last updated on 12/1/00;
Send questions about this page to: Ed Tong
or contact Wheaton College.