Vital signs my friends. Vital signs. If I had not looked at this young man's vital signs I would have let him sit for a while with his chest pain. After all he was an 18 year old without trauma. What's the worst it could be? The nurse did document a pulse of 140 but somehow triaged him to a low category. I saw the pulse rate and went back to see this young man who was looking quite ill.
Now the dogma is that you never want to diagnose a tension pneumothorax by Xray but that is in fact what happened here. Without trauma it was not apparent to me to even think about it and he was maintaining his oxygen saturations. I did suspect a pneumothorax in this tall thin kid who smoked but I did not expect this.
As you can see from the first film there is a very clear looking right lung field. The busy-looking hilar area on the right near the middle is his right lung, fully collapsed, and, if you look closely you can see the trachea deviated into the left lung field.
As soon as I saw the Xray we moved him to a critical bed and I stuck a 14 angiocath between the 4th and 5th ribs on the right. There was no dramatic rush of air so I think this was early tension, but when I put in the chest tube (seen clearly in the mostly re expanded left lung apex) I did get a nice rush of air.
Concerningly, this young man's lungs do not appear normal after the chest tube so suspicion is raised for an underlying undiagnosed disorder like alpha 1 antitrypsin deficiency. Vital signs people. 18 year olds with chest pain sometimes have a life threatening cause and we can not miss them.