Ectopic chest tube insertions: diagnosis and strategies for prevention

In the six-month period from October 1999 to March 2000, the authors carried out a prospective study of ectopic chest tube placements (ECTP) diagnosed at the Assir Central Hospital, Abha, Saudi Arabia. During the reference period, 63 chest tube placements were carried out in 44 patients while one patient was from a medium-sized general hospital within a neighbouring city. The grades of the surgeons who had performed the ECTP were: surgeon specialists based at peripheral hospitals--5 (83.3%), and surgical resident in training at the regional referral centre--1 (16.7%). Mean age = 29.7 years; M:F ratio = 2:1. A total of 6 cases of ECTP were found constituting 9.5% of all chest tube insertions mostly from small hospitals situated in the peripheral, non-urban areas. The diagnosis of ECTP was made on plain chest radiographs in 3 patients (50%) and on the CT scans of the chest in 3 patients (50%). The ECTP was into the lung (2 cases--33.3%), subdiaphragmatic. intraabdominal (3 cases--50%), and chest wall, subcutaneous (1 case--16.7%). Misdiagnosis and failure to carry out a finger exploration of the pleural cavity prior to the placement of the chest tube rather than the use of chest tubes with trocars was to blame. The incidence of ECTP (9.5%) is high and underlines the need for proper training in the methodology of chest tube insertion for junior surgical cadre.