TILIF #2: Planes, train(ing)s, and how a heart heals

I think today marks the end of my official orientation activities for this job. Maybe? We needed to be oriented to the University, to the Department of Pediatrics, and to the Division of Pediatric Critical Care - each with their own priorities and complicated logistics to communicate. There was an amusing progression from less to more relevant information and tours of smaller and smaller areas.

For example:

"Over there is the children's hospital!"

to

"This floor is the PICU!"

to

"This corner of this storeroom is where the ultrasound machines are kept!"

Of course the end of orientation implies that I now know the minimum information to do this job, which is surprising. I guess the important thing is I know where to find any information I'm missing going forward.

TILIF: Always place a chest tube for any size pneumothorax before transporting the patient by air. A pneumothorax (pneumo- = air, -thorax = chest) is when you have air in your chest but outside your lungs. This can be caused by external trauma (e.g. knife to the chest) or internal trauma (e.g. popping a lung from having too high of ventilator settings). The problem with this is the air has no where to go and will continue to fill up the chest, taking up the space that the lungs and heart need in order to work. A small pneumothorax is no big deal and will be reabsorbed by the body in time; a large one will tamponade the heart, preventing it from filling with blood and killing the patient.

If you are transporting a patient by air, the lower pressure experienced even in a pressurized cabin* will allow any air of a pneumothorax to expand to a larger volume, which, per the principles above, could be deadly. Accordingly, before putting someone with a pneumothorax on a plane, have the referring hospital put in a chest tube, so that any increasing volume of air can be safely vented thanks to a one-way valve on the tube. Pro-tip: flush the chest tube with some water to minimize any additional air in the tubing that might expand at altitude.

I also learned, there are two broad types of heart transplant: orthotopic and heterotopic, aka "piggyback." Orthotopic is basically what you think of as a transplant, when you put the patient on bypass, take out the old heart, put in the new heart, and take the patient off bypass. Heterotopic heart transplants are much less common and consist of leaving the old heart in the patient and installing the new one, essentially in parallel. A reason you might attempt this is if the native heart just needs time to recover from some insult but has the potential to return to full strength in the future. Additionally, a benefit of keeping the old heart in place is that you can fall back on it if the new one goes into acute transplant rejection. However, this type of transplant is much more complex and not seen as worth the risk now that we have better anti-rejection medications.

*Bonus fact: Airplanes at cruising altitude are pressurized to the equivalent of 8000 feet, not sea level. So, one of the first things that is requested by health care professionals if there is a medical emergency on a plane is for the pilot to fly the plane to the lowest safe altitude. This is effectively like putting an oxygen mask on the patient, just because the partial pressure of oxygen is so much higher near the ground than at cruising altitude.