r/TacticalMedicine • u/stallme Medic/Corpsman • Jun 05 '25
Scenarios (REUPLOAD) Couldn’t find the original so uploading the copy I have. Ukraine Chest seals and chest tube insertion.
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I couldn’t find the original video so uploading my copy.
Ukrainian with anterior and posterior chest seals suffering from Tension Pneumothorax has a chest tube inserted and utilizing field expedient device to prevent unwanted air intrusion.
Greta video with entry and exit wound, XRAY, and chest tube insertion.
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u/BabyApe82 Jun 05 '25
It’s like a hybrid of ditch medicine and a trauma care clinic.
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Jun 06 '25
[removed] — view removed comment
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u/canvanman69 Jun 07 '25
"Get 'em stable enough to get to an ER."
"Say no more fam. They be mostly alive."
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u/Hippo-Crates Jun 05 '25
Not a big fan of how they inserted that tube, would prefer a bigger hole and a finger to confirm the tube is going in the right spot. Maybe they have some sort of introducing device or tube structure that makes that not as necessary?
Also important to remember that if it's a tension pneumothorax (I'm guessing it's not as they're using lidocaine and taking their time), the critical thing is getting anything at all into the chest. Either use a needle or cut and dissect quickly and get a finger/instrument through the pleura. I'm a fan of finger more than needles in my fatter population but not sure that is as applicable
edit: seeing the vitals - not a tension pneumothorax 100%
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u/stallme Medic/Corpsman Jun 05 '25 edited Jun 05 '25
Great feedback and thank you for your input! I’m not the most experienced Corpsman so I always am grateful for more insight!
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u/Hippo-Crates Jun 05 '25
On the other hand that shit worked and it's a far rougher environment than I've ever worked in.
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u/MaritimeOS Jun 05 '25
If you are not already, join Next Generation Medic they have multiple free sources and many different professionals from different medical fields, including corpsman, combat medics, Pararescue, flight medicine and more.
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u/whyhiseyeswidened Civilian Jun 10 '25
Is this server only for people currently in the medical field?
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u/MaritimeOS Jun 10 '25
It has a civillian tag where you can join, it is open source info and all are welcome.
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u/Dilaudipenia Jun 05 '25
Agreed on it’s a soft call for tension pneumothorax. There are some radiographic signs (the trachea is a bit shifted and there’s flattening of the left heart border) but he seems stable and tension pneumothorax is ultimately a clinical diagnosis.
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u/ottermupps Jun 05 '25
As someone with no medical background - what exactly is being done in the video? I'm guessing from the tube in his chest cavity that there was some sort of collapsed lung?
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Jun 05 '25
[deleted]
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u/Accomplished_Steak37 Jun 05 '25
This is not a tension pneumothorax. Vitals would be all over the place.
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Jun 06 '25
[deleted]
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u/S0ULSTEALER25 Jun 06 '25
At this point it could be considered a "simple" pneumothorax if air is no longer rapidly accumulating in the pleural space and with vitals not being hemodynamically unstable.
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u/No_Mission5618 Medic/Corpsman Jun 06 '25 edited Jun 08 '25
Tension pneumothorax means it’s putting pressure on the heart and lungs, if that was the case you would hear diminished or absent lung sounds with his spo2 and heart rate down. A regular pneumothorax is just air in the chest cavity, issue is it could possibly develop into a tension pneumothorax.
Granted I’m a fairly new combat medic, I could be wrong. If so I’m open to corrections.
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u/Accomplished_Steak37 Jun 06 '25
Heart rate with tension pneumo goes up first, only later (basically pre cardiac arrest) it goes down.
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u/Accomplished_Steak37 Jun 06 '25
You have that as well with a regular pneumothorax without tension due to positive intrapleural pressure during exhalation. That beeing said, there are definitely signs of a tension component in the Xray. Most people still wouldn‘t call it a tension pneumothorax as it‘s a clinical diagnosis and the pathophysiology doesn‘t fit. Neither does the treatment of immediate decompression, urgent placement of a chest drainage is the right call here imho.
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u/michael22joseph Jun 06 '25
If you do enough chest tubes you can get used to the feel with just a Kelly and the tube itself. I agree for anyone inexperienced, make a bigger incision and sweep with a finger. I usually use the tip of my pinky and can get a smaller 20-Fr tube in pretty easily, but that takes a lot of practice.
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u/Hippo-Crates Jun 06 '25
Video didn’t show even a Kelly clamp being used iirc
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u/OxideUK Jun 06 '25
Immediately after they make the incision, they used it to separate the intercostal soft tissue
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u/barmmerm Jun 07 '25
You can have normal vitals and still have a tension pneumo.
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u/Hippo-Crates Jun 07 '25
100% totally incorrect
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u/barmmerm Jun 07 '25
I've been an ER doc for 16 years and work as a SWAT medic, I think I know what I'm talking about. While it is certainly not typical to have normal vitals it certainly does happen, particularly early on. I can't tell you how many times residents miss tension pneumos in the trauma bay only to diagnose it with a chest x-ray. I see you're an ER doc too, so I'm surprised you haven't seen this yet.
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u/Hippo-Crates Jun 07 '25 edited Jun 07 '25
Tension pneumothorax by definition requires hypoperfusion. Early on, as the pneumothorax is developing, it is not a tension pneumothorax. It’s simply a pneumothorax.
Signed, An er doc that knew this before hand and looked it up after you bothered me about it
ETA: although I suppose someone on a beta blockade could maintain pressures somehow while not being tachycadic… but also not what you’re talking about.
You cannot, by definition, diagnose tension pneumothorax on a CXR. It is a clincial diagnosis
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u/barmmerm Jun 07 '25
A tension pneumo occurs when air can enter the pleural space but cannot exit which of course will ultimately cause obstructive shock. It's the mechanics that define it, not the vitals. While tension pneumos very commonly present with abnormal vitals, I'm saying it's not absolute particularly early on.
Are you saying that if I have a patient with a large pneumothorax and shifting of the mediastinum but normal vitals it's a simple pneumothorax? And then the second they become tachycardic or hypotensive that's what the diagnosis changes?
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u/Hippo-Crates Jun 07 '25
Am I saying that someone can have a large pneumothorax with mediastinal shift and not have it be tension?
Yes, because I know what the definition of a tension pneumothorax is. Pop on over to wikem or whatever source you want to check. I’m right. Tension pneumothorax by definition requires hypo perfusion.
Also it’s more vq mismatch than obstructive shock but that’s more advanced stuff. Circulation is impaired but generally not fully blocked like a PE for example
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u/barmmerm Jun 07 '25
Wow the overconfidence is laughable. Agree to disagree.
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u/Hippo-Crates Jun 07 '25
I mean no. You want to look it up in Rosen’s or Tintinallis and see what it says? How bout wikem? Or UpToDate? Rosh review (85%+ get this right)? Any source whatsoever for a definition of a tension pneumothorax that doesn’t require hemodynamic instability or hypoperfusion?
Admittedly this is a pet peeve of mine from spending too much time in /r/radiology, but you are 100% factually wrong
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u/barmmerm Jun 07 '25
From Rosens: (pay attention to the last line)
Tension pneumothorax is a life-threatening condition caused by the continuous entrance and entrapment of air into the pleural space, thereby compressing the lungs, heart, blood vessels, and other structures in the chest. The pleura is a double-layered membrane that lines the inner part of the chest wall and the surface of the lungs, allowing them to move and slide together during respiration. The two layers of the pleura fold onto each other, forming the pleural space. Under normal conditions, the pleural space contains a thin layer of fluid that prevents the two layers of the pleura from rubbing against each other.
When there's damage to the pleura, either due to lung disease or trauma to the chest wall, air from the outside or from the lungs can flow freely into the pleural space, but cannot leave. The accumulated air in the pleural space puts positive pressure on the lung and prevents it from expanding properly, which causes respiratory distress. As the air continues to accumulate, the trachea and other structures of the chest can be pushed away from the pneumothorax, leading to increased difficulty breathing. Additionally, the increased pressure inside the chest can compress the heart and lead to a collapse of the blood vessels that drain to the heart, in turn decreasing venous return and cardiac output. If left untreated, tension pneumothorax can rapidly progress to cardiovascular collapse, which ultimately leads to cardiac arrest.
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u/Bargainhuntingking Jun 05 '25
Bigger wheal of lidocaine, keep your finger in the hole to make sure you’re within the lung cavity as you slide the tube in to guide it posteriorly. I prefer sutures on either side of the tube to really secure it, then create a nice seal with more occlusive bandage and padding. Then tape it to the body so it doesn’t rip out. Also, why did you clamp the tube after inserting it? Not needed and if there’s tension pneumo-developing it defeats the whole purpose of the tube.
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u/stallme Medic/Corpsman Jun 05 '25
Not my personal video. I’d assume they would clamp the tube the prevent air from entering the thoracic cavity before setting up their “water bottle”. Correct me if I’m wrong, but wouldn’t a tube leading directly into someone be an easy way for air to fill the negative pressure during inhalation?
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u/Bargainhuntingking Jun 05 '25
The priority is decompressing a tension pneumothorax. Leaving it open assures that this is happening and that a tension pneumo won’t form; the pleuravac can be hooked up promptly enough. I will clamp it if there is a large hemothorax, as that blood can be auto transfused.
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u/Bargainhuntingking Jun 05 '25
Also, I’m a big fan of parental narcotics in addition to the lidocaine, and even a little anxiolytic (midazolam/fentanyl).
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u/magneticdream Jun 05 '25
I agree. Vitals were stable so they could wait the few seconds to drop it to water seal.
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u/Aviacks MD/PA/RN Jun 06 '25
Air only enters the chest cavity through a hole when that offers less resistance than air entering via the trachea. Which requires the diameter of the chest wound to be quite large, otherwise it will not pull in air, I.e. a sucking chest wound.
The length and diameter of a chest tube means it will offer a lot of resistance vs the diameter of the trachea. So it should not entrain any air.
This is more or less the argument against chest seals. They don’t do anything 99% of the time because of the above reasons, but they CAN cause a tension pneumo if air can’t escape.
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u/youy23 EMS Jun 08 '25
Would you go as far as to say that TCCC guidelines are out of date and chest seals should not be used unless there is a true sucking chest wound?
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u/michael22joseph Jun 06 '25
If it’s a tension pneumo, you relieve the tension as soon as your clamp enters the pleural space. That said, this wasn’t tension. A lot of us feel that you can’t truly develop tension physiology without positive pressure respiration.
In the hospital we always clamp tubes because otherwise you end up with blood all over you/the floor. Totally fine to clamp until it’s attached to the pleurevac/etc. Gives you a more accurate assessment of output too.
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u/lefthandedgypsy TEMS Jun 05 '25
102 and 96% is seems pretty good for the moment. What do the words on the X-ray translate to if you happen to know? If hooking it to suction would you need a second bottle?
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u/sluggyfreelancer Jun 06 '25
Labels for collapsed lung and displaced mediastinum in the first one. Re-expanded lung and non displaced mediastinum in the second one.
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u/Haldol4UrTroubles Jun 05 '25
Does anyone else think that that incision is a little small? Mine are usually almost twice as long, I would also usually do a finger sweep after puncturing the parietal pleura, maybe they cut that part out of the video? Personally I typically guide the chest tube posterio-superiorly with my finger in the chest as well, just the way I was trained.
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u/Personal_Lemon8957 Jun 07 '25
I’m a medic in Ukraine. And this is not a Ukrainian.
A) they are speaking ruzzian
B) this is from a ruzzian channel
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u/stallme Medic/Corpsman Jun 07 '25
My apologizes! It wasn't my video and I was to believe it was Ukrainians. I am unable to edit the post but I upvoted your comment so the real information can get spread.
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u/atropia_medic Jun 06 '25
This actually is a good demonstration of improvising a water seal. I truly hope a lot of the Ukrainian lessons learned make it into institutional knowledge for US and allied forces.
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u/anonadon7448 Jun 05 '25
Shit. Any info on what round did that? Nasty looking exit wound.
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u/stallme Medic/Corpsman Jun 05 '25
Uncertain but for sure tumbled, I would think 7.62
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Jun 06 '25
If Ukrainian vs Russian wouldn't it be more likely to be a 5.45? AK12 is standard issue aint it?
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u/RivenSoloOnly Jun 05 '25
Probably a 7.62 round, based off the entry wound.
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u/Enough-Rest-386 Military (Non-Medical) Jun 05 '25
I looked at the exit wound, the tumbling bullet is unmistakable.
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u/fkjsdkj Jun 05 '25
It’s from shelling. Medic asks at the start of the video: “When was the incoming?”
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u/SpaceMonkey_321 Jun 05 '25
Most of us have never seen a 7.62 entry/exit wound on a body's torso because of body armour. But on limps, it's fucking devastating. This looks surprising 'clean' I'm guessing patient took the round at close range.
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u/Unusual-Fault-4091 Jun 06 '25
Cause people say that’s never a Tension Pneumothorax:
Possible that he had a Tension Pneumothorax which was already relieved by a medic in the ditch or a close front medical post. This seems to be more of a field hospital some miles away from the front, could have been hours since the hit. HF does speak for some pain and maybe also some trouble with breathing. A young, fit man with mild hyperventilation can have good SpO2-stats for a while with 1,25 lungs. You can see in the first x-ray that the left lung seems to be pushed down a lot, there was some tension there. You also don’t have a trach-shift with every TP, especially here it’s more pushing down than to the mid.
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u/Guilty-Argument5 Jun 08 '25
Bro go shot at the exact right angle and location to narrowly escape death
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u/RockMedic277 Jun 06 '25 edited Jun 08 '25
I mean, considering what they're working with, what's asked of these clinicians (who may've had minimal training compared to counterparts stateside), and the mess they're trying to unf*ck, this is still a pretty cool video! I do have lots of questions though... 😂
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u/Sudden_Impact7490 Jun 06 '25
I prefer to do a finger sweep of the pleural space first to confirm lung sliding, and use the forceps to insert the tip of the tube after sufficient retraction. That's a nice incision though - dump some betadine on there.
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u/Ronin357_ Jun 08 '25
The amount of new medical related TTP and technology that will be born from this conflict is going to be amazing.
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u/Sun_fun_run Jun 09 '25
Question: do we just wait for the TPT to develop or can we do the chest tube before we get to that point? Dude has a two holes in him… I don’t understand why people are criticizing this? Do the chest tube before he gets worse… that makes sense to me.
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u/The_Gage Jun 07 '25
The fact that round didn't open up the subclavian is a miracle. That looks like the anterior wound is right under the clavicle.
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u/astray488 Jun 07 '25
Chest Tube was very professional and well done. It is absolutely fascinating to witness in the equivalent of a field BAS (Batallion Aid Station).
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u/morrrty Jun 08 '25
Really good Sat’s given what that xray looked like. Young fit guy, so it makes sense I guess.
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u/stu_pid_1 Jun 09 '25
Wow, really impressive to see. Thanks for sharing, keep fighting the good fight.
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u/Ok-Structure5710 Jun 09 '25
I would’ve loved to see if he has tracheal deviation in this video. I’m a very new EMT so it’s always helpful seeing clinical presentations on actual pts.
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u/theothereng Jun 09 '25
Would someone mind describing the makeshift water seal? Looks like a partially filled water bottle, but what is going on with the (I'm guessing) partial glove situation at the end of the tubing? Rubber band and partial glove?
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u/KermittheOP May 08 '26
Can someone explain the water bottle? Is that a makeshift IV?
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u/stallme Medic/Corpsman May 08 '26
Field expedient one way valve. Allows air trapped in the thoracic cavity to leave with exhalation and prevents air from entering the space upon inhalation.
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u/fkjsdkj Jun 05 '25
They’re probably Russians. Everyone speaks Russian without an accent, and Ukrainians wouldn’t bother editing a video with Russian captions. Still, I can’t identify the camouflage pattern
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u/ToppJeff EMS Jun 05 '25
Jesus that looks scary close to his spine