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Original article
The modified ‘Jo’burg’ technique for securing intercostal chest drains Daniel J Ablett,1,2 L Navaratne,1,2 D Chua,3 C G Streets,2,4 N R M Tai1,2 1
Royal London Hospital, London, UK 2 Defence Medical Services, DMS Whittington, Lichfield, UK 3 Royal College of Surgeons of Ireland, Dublin, Ireland 4 Bristol Royal Infirmary, Bristol, UK Correspondence to Maj L Navaratne, Flat 174 Compass House, Smugglers Way, London SW18 1DJ, UK; [email protected] Received 14 November 2016 Revised 15 March 2017 Accepted 18 March 2017
ABSTRACT Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.
INTRODUCTION
To cite: Ablett DJ, Navaratne L, Chua D, et al. J R Army Med Corps Published Online First: [please include Day Month Year] doi:10.1136/jramc2016-000744
Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel, 76% of insertions in one large study,1 as an emergency procedure during the initial resuscitation period and often within a stressful environment. It is associated with significant complication rates of approximately 20%1–3 and in a retrospective review of over 1000 ICD insertions, 7% of the complications were due to inadequate fixation, resulting in dislodgement.1 In the civilian prehospital setting, performance of thoracostomies alone is standard practice in patients receiving positive pressure ventilation4
Key messages ▸ Approximately one-fifth of intercostal chest drain (ICD) insertions are associated with significant complications. ▸ The method of securing ICDs has not been standardised across the Defence Medical Service (DMS). ▸ The ‘Roman Sandal’ technique for securing ICDs is associated with a high failure rate. ▸ The modified Jo’burg technique is a robust, easily teachable and reproducible technique for securing ICDs. ▸ The modified Jo’burg technique should be implemented as the preferred method of choice within the DMS by introducing it into the various military trauma courses.
with replacement by ICDs through the thoracostomy wounds on arrival at the emergency department. In the military setting, especially in an era of contingency operations, where transit times may be prolonged, an ICD might be inserted before arrival at a Medical Treatment Facility. If an ICD is not secured adequately it may become dislodged resulting in the drain being pushed in such that it kinks and blocks, the drain being pulled out such that one or both of the drainage holes sit outside the pleural cavity or the drain being pulled out completely. Dislodgement of an ICD may be associated with significant morbidity and so use of a robust technique to secure an ICD is essential. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines,5 the method of securing ICDs has not been standardised across the Defence Medical Services (DMS) or, indeed the wider healthcare community. A recent UK military study6 revealed the use of a variety of techniques with some being more effective than others; in particular there was widespread use of the ‘Roman Sandal’ technique which had a failure rate of one third. This technique involves creating a single temporary node to close the wound around the tube followed by passing the two suture ends around the tube in a Roman Sandal pattern (Figure 1).7 The authors concluded that this method should be discouraged as it involves elliptical ties around a circular tube, which can loosen easily. While certain features of the different observed techniques were recognised as being effective, no single technique was identified that could be recommended as the ‘gold standard’.
Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
1
Downloaded from http://jramc.bmj.com/ on September 18, 2017 - Published by group.bmj.com
Original article (GCC-90, 3/8 circle, 90 mm, conventional cutting needle) is recommended as this is less likely to snap than silk, and the hand-held needle is quick to use. The suture securing the drain is used to close the skin incision at the time of drain removal, and so it is important to only tie the suture with a single throw during step C (Figure 2), as if a reef knot is tied at this stage then drain removal will leave an opening and the existing suture will have to be cut and removed and another stitch placed to close the wound. It is important to cut the two ends of the suture long enough to tie by hand (or instrument tie if required) when releasing the drain. Removal of this suture can then take place 7–10 days later. This part of the procedure should be conducted by doctors or appropriately trained nursing staff.
PILOT VALIDATION STUDY The aim of this pilot validation study was to assess whether the modified Jo’burg technique for securing ICDs provided junior medical personnel with a technique that was easy to teach, easily reproducible and above all resulted in robustly secured ICDs that would withstand dislodgement within a military or austere prehospital environment.
METHODS
Figure 1 Roman Sandal technique for securing intercostal chest drains. This paper proposes a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand and presents the results from a pilot validation study of this technique.
The modified Jo’burg technique The original ‘Jo’burg technique’8 has since been modified to employ a horizontal mattress suture rather than the originally described vertical mattress suture (Figure 2).9 The use of a horizontal mattress suture results in good fixation of the tube and an airtight closure of the chest wall after removal, with a cosmetically satisfactory result.10 There are several features of the modified technique that make the ICD fixation more secure: the horizontal mattress suture acts as a purse string to prevent air leakage, the tube is secured at skin level and again higher up to minimise longitudinal movement, pulling on the ICD tightens both levels of fixation and the horizontal mattress and tying the mattress suture when the drain is removed closes the wound effectively without the need for additional sutures. The steps described here use forceps to assist in passage of the suture under the extracorporeal suture loop, as described previously,9 but the suture is not pre-tied at the start of the procedure, making the technique easier to perform and not affecting the integrity of the technique. Non-surgical practitioners may not be familiar with hand tying so we also demonstrate how the technique can be performed using instrument ties by using the forceps to maintain tension while performing the floating knot (Figure 2G*) and stabilise the suture as it is tied on to the ICD to ensure it is tied tightly (Figure 2H*). A heavy size 0 or 1 nylon suture on a hand-held cutting needle 2
Fourteen junior surgical trainees attending a practical surgical training course were asked to secure an ICD on a cadaveric porcine model without direction as to which technique should be used; an assistant was provided. Once completed, the secured ICD was inspected and photographed. The depth of tube insertion (in cm) at the level of the skin was recorded. After securing the ICD, the two ends of the suture material were deliberately left long and a floating knot was tied to create a loop. Testing for robustness and potential for dislodgement was first performed by vigorously pushing and pulling on the ICD three times by the same examiner. Second, a Newton force metre (Force Tester with Newton Division, PCE Instruments UK Limited, Southampton, UK) was hooked through the loop created at the end of the suture to apply a constant ‘dislodging’ force of 50 N (equivalent to ∼5 kg) for 10 s to simulate expected ICD movements during combat casualty transfer. Dislodgement was then measured in centimetres (‘dislodgement score’) calculated as a sum of inward and outward movement when compared with the original depth of tube placement, for example 2 cm inward movement and 4 cm outward movement would be recorded as a dislodgement score of 6 cm. All trainees answered a short four-part questionnaire providing information on their previous experience with ICD insertion, whether they had received formal or informal teaching on how to secure ICDs, and finally whether they were aware of or had ever used the Jo’burg technique previously. The modified technique was then explained and demonstrated to the trainees with further 10 min allocated to practice the technique under supervision. Each trainee (with an assistant) then attempted to perform the technique unsupervised; the secured ICD was inspected to assess whether the modified Jo’burg technique had been performed correctly and was tested for security in the same way as before.
RESULTS Overall, 6/14 (43%) junior surgical trainees had never inserted an ICD prior to the study, 4 (29%) had intermediate experience with 1–9 insertions and 4 had inserted more than 10 ICDs. Almost 80% of the candidates had received formal or informal teaching on how to secure ICDs, but none of the 14 was aware Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
Downloaded from http://jramc.bmj.com/ on September 18, 2017 - Published by group.bmj.com
Original article
Figure 2 The modified Jo’burg technique for securing an intercostal chest drain (ICD). (A) Insert the intercostal drain in the standard manner. (B) Using an appropriately robust suture, insert a horizontal mattress suture (incorporating the drain) with the extracorporeal loop positioned superiorly. Pull the two ends of the suture so that they are equal in length and remove the needle. (C) Place the tips of haemostatic forceps (held by an assistant) under the loop and tie the suture tightly inferior to the drain with a single throw. (D) Wrap both lengths of the suture tightly several times around the drain at the level of the skin. (E) Ensuring that tension is maintained, grasp both of the lengths of suture with the haemostatic forceps. (F) Again, ensuring that tension is maintained, pull the sutures under the loop. (G) Tie a floating knot approximately 2–3 cm from the skin level. (H) Wrap the sutures around the drain several times and tie tightly. Cut the suture and then apply a suitable air-tight dressing. Alternative technique (for medical personnel preferring to instrument tie). (G*) Hold the suture with the forceps, maintaining tension, while performing an instrument tie to create the floating knot. (H*) Hold the first throw of the suture with the forceps while instrument tying the suture on to the ICD.
of or had previously used the Jo’burg technique for securing an ICD. Table 1 shows the results of the pilot validation study showing individual trainee experience of ICD insertion, the chosen method during their first attempt and its corresponding dislodgement score. All trainees performed the modified Jo’burg technique correctly and the corresponding dislodgements cores are presented. The ‘Roman Sandal’ technique was used by 10/ 14 (71%) trainees on their first attempt with a median dislodgement score of 5 cm, compared with median 0 cm for the modified Jo’burg technique ( p10 0 >10 0 1–4 0 0 >10 0 1–4 5–9 >10
SSS; half stitches SSS; FRS SSS; FRS SSS; FRS SSS; FRS SSS; FRS Horizontal mattress; FRS SSS; FRS SSS; FRS SSS; floating single level at 2 cm Horizontal mattress; secured at skin level SSS; FRS SSS; FRS SSS; Single level tie at 2 cm
8 6 6 6 6 2 4 3 7.5 3 0 10 3 3
0 0 0 0 0 0 0 1 0 0 0 1 0 0
The two right columns demonstrate whether the modified Jo’burg technique was correctly performed at the second attempt with its corresponding dislodgement score. FRS, floating Roman Sandal technique; ICD, intercostal chest drain; SSS, Single skin suture.
0 cm), suggesting that without dedicated instruction of a robust, easily reproducible method of securing ICDs, the current methods used by junior trainees could lead to suboptimal acutephase care of the trauma patient. After the period of instruction and supervised practice, all trainees were able to perform the modified Jo’burg technique correctly resulting in securely inserted ICDs, suggesting it can be easily taught to junior staff and replicated to a satisfactory standard. The questionnaire answered by all the trainees after their first attempt highlighted the range of previous experience of ICD insertion with almost half of the trainees never having inserted an ICD before. This may well be in part due to regionalisation of UK trauma systems and major trauma centres within the last 7 years with only few trainees receiving adequate exposure to trauma training during their normal daily medical practice. This places even more emphasis on incorporating a standardised technique of ICD insertion into our military trauma courses for junior trainees. Furthermore, various military courses such as the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses, are aimed at established consultants (regular and reserve) with limited trauma experience or exposure in their routine practice and a standardised technique, adopted across the DMS, may also be useful. The relative lack of experience of ICD insertion also demonstrates that if any ‘new’ technique is deemed to be effective, it is likely to be a method that is easily reproducible and taught to junior medical personnel. There are limitations to this pilot study. First, the sample size of trainees taking part in the study is small and may not truly represent the target population of medical personnel deploying on military operations. However, the study was designed to evaluate trainees before and after instruction of the modified Jo’burg technique rather than comparing two groups that were not matched; in doing so, the small sample size of 14 subjects serve as their own control group (initial attempt). Second, the initial step for assessing robustness and dislodgement required the examiner to push and pull the ICD ‘vigorously’ three times. Although the same examiner was used throughout the study, a degree of variation will undoubtedly 4
exist in the forces used. Third, the Newton force metre used in this study had an analogue rather than a digital scale. This may result in greater measurement errors while also making it more difficult for the examiner to apply a constant force during the 10 s period. This pilot study can form the basis of future studies. Recruiting participants from the target population of military doctors may provide a more representative sample population and facilitate comparison between various groups such as trainees versus consultants and surgeons versus emergency physicians. Measuring the forces required to produce a certain amount of dislodgement (eg, 2 cm of outward displacement) may also eliminate the technical issues of producing a constant force over a fixed time period.
CONCLUSION This small pilot study shows that the modified Jo’burg technique can be easily taught to junior medical personnel and can be reproduced to a good standard, and we would advocate the use of this technique among both surgically and nonsurgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. Acknowledgements Mr John Taylor, course director of RCS(Eng) Surgical Skills in Emergency and Trauma. Contributors DJA: concept of study, performing the study, data collection, editing of manuscript. LN: data analysis, writing of manuscript. DC: performing the study, data collection, editing of manuscript. CGS and NRMT: editing of manuscript. Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3
Kong VY, Oosthuizen GV, Sartorius B, et al. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa. Ann R Coll Surg Engl 2014;96:609–13. Chan L, Reilly KM, Henderson C, et al. Complication rates of tube thoracostomy. Am J Emerg Med 1997;15:368–70. Etoch SW, Bar-Natan MF, Miller FB, et al. Tube thoracostomy. Factors related to complications. Arch Surg 1995;130:521–5; discussion 525–6.
Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
Downloaded from http://jramc.bmj.com/ on September 18, 2017 - Published by group.bmj.com
Original article 4
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Aylwin CJ, Brohi K, Davies GD, et al. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl 2008; 90:54–7. American College of Surgeons. Advanced trauma life support. 9th edn. Chicago, IL, USA: ACS, 2012. Howes RJ, Calder A, Hollingsworth A, et al. The end for the ‘Roman Sandal’: an observational study of methods of securing chest drains in a deployed military setting. J R Nav Med Serv 2015;101:42–6.
Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
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Inzirillo F, Giorgetta C, Ravalli E, et al. “Roman Sandal” modified method for securing the chest drain to the skin. Gen Thorac Cardiovasc Surg 2013;61:171–3. Plani F. Securing intercostal drains in trauma surgical practice—how I do it. CME 2004;22:388–90. Maritz D, McLauchlan C. A novel way to secure a chest drain. Ann R Coll Surg Engl 2014;96:82. Rashid MA, Wikström T, Ortenwall P. A simple technique for anchoring chest tubes. Eur Respir J 1998;12:958–9.
5
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The modified 'Jo'burg' technique for securing intercostal chest drains Daniel J Ablett, L Navaratne, D Chua, C G Streets and N R M Tai J R Army Med Corps published online June 26, 2017
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Original article
The modified ‘Jo’burg’ technique for securing intercostal chest drains Daniel J Ablett,1,2 L Navaratne,1,2 D Chua,3 C G Streets,2,4 N R M Tai1,2 1
Royal London Hospital, London, UK 2 Defence Medical Services, DMS Whittington, Lichfield, UK 3 Royal College of Surgeons of Ireland, Dublin, Ireland 4 Bristol Royal Infirmary, Bristol, UK Correspondence to Maj L Navaratne, Flat 174 Compass House, Smugglers Way, London SW18 1DJ, UK; [email protected] Received 14 November 2016 Revised 15 March 2017 Accepted 18 March 2017
ABSTRACT Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.
INTRODUCTION
To cite: Ablett DJ, Navaratne L, Chua D, et al. J R Army Med Corps Published Online First: [please include Day Month Year] doi:10.1136/jramc2016-000744
Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel, 76% of insertions in one large study,1 as an emergency procedure during the initial resuscitation period and often within a stressful environment. It is associated with significant complication rates of approximately 20%1–3 and in a retrospective review of over 1000 ICD insertions, 7% of the complications were due to inadequate fixation, resulting in dislodgement.1 In the civilian prehospital setting, performance of thoracostomies alone is standard practice in patients receiving positive pressure ventilation4
Key messages ▸ Approximately one-fifth of intercostal chest drain (ICD) insertions are associated with significant complications. ▸ The method of securing ICDs has not been standardised across the Defence Medical Service (DMS). ▸ The ‘Roman Sandal’ technique for securing ICDs is associated with a high failure rate. ▸ The modified Jo’burg technique is a robust, easily teachable and reproducible technique for securing ICDs. ▸ The modified Jo’burg technique should be implemented as the preferred method of choice within the DMS by introducing it into the various military trauma courses.
with replacement by ICDs through the thoracostomy wounds on arrival at the emergency department. In the military setting, especially in an era of contingency operations, where transit times may be prolonged, an ICD might be inserted before arrival at a Medical Treatment Facility. If an ICD is not secured adequately it may become dislodged resulting in the drain being pushed in such that it kinks and blocks, the drain being pulled out such that one or both of the drainage holes sit outside the pleural cavity or the drain being pulled out completely. Dislodgement of an ICD may be associated with significant morbidity and so use of a robust technique to secure an ICD is essential. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines,5 the method of securing ICDs has not been standardised across the Defence Medical Services (DMS) or, indeed the wider healthcare community. A recent UK military study6 revealed the use of a variety of techniques with some being more effective than others; in particular there was widespread use of the ‘Roman Sandal’ technique which had a failure rate of one third. This technique involves creating a single temporary node to close the wound around the tube followed by passing the two suture ends around the tube in a Roman Sandal pattern (Figure 1).7 The authors concluded that this method should be discouraged as it involves elliptical ties around a circular tube, which can loosen easily. While certain features of the different observed techniques were recognised as being effective, no single technique was identified that could be recommended as the ‘gold standard’.
Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
1
Downloaded from http://jramc.bmj.com/ on September 18, 2017 - Published by group.bmj.com
Original article (GCC-90, 3/8 circle, 90 mm, conventional cutting needle) is recommended as this is less likely to snap than silk, and the hand-held needle is quick to use. The suture securing the drain is used to close the skin incision at the time of drain removal, and so it is important to only tie the suture with a single throw during step C (Figure 2), as if a reef knot is tied at this stage then drain removal will leave an opening and the existing suture will have to be cut and removed and another stitch placed to close the wound. It is important to cut the two ends of the suture long enough to tie by hand (or instrument tie if required) when releasing the drain. Removal of this suture can then take place 7–10 days later. This part of the procedure should be conducted by doctors or appropriately trained nursing staff.
PILOT VALIDATION STUDY The aim of this pilot validation study was to assess whether the modified Jo’burg technique for securing ICDs provided junior medical personnel with a technique that was easy to teach, easily reproducible and above all resulted in robustly secured ICDs that would withstand dislodgement within a military or austere prehospital environment.
METHODS
Figure 1 Roman Sandal technique for securing intercostal chest drains. This paper proposes a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand and presents the results from a pilot validation study of this technique.
The modified Jo’burg technique The original ‘Jo’burg technique’8 has since been modified to employ a horizontal mattress suture rather than the originally described vertical mattress suture (Figure 2).9 The use of a horizontal mattress suture results in good fixation of the tube and an airtight closure of the chest wall after removal, with a cosmetically satisfactory result.10 There are several features of the modified technique that make the ICD fixation more secure: the horizontal mattress suture acts as a purse string to prevent air leakage, the tube is secured at skin level and again higher up to minimise longitudinal movement, pulling on the ICD tightens both levels of fixation and the horizontal mattress and tying the mattress suture when the drain is removed closes the wound effectively without the need for additional sutures. The steps described here use forceps to assist in passage of the suture under the extracorporeal suture loop, as described previously,9 but the suture is not pre-tied at the start of the procedure, making the technique easier to perform and not affecting the integrity of the technique. Non-surgical practitioners may not be familiar with hand tying so we also demonstrate how the technique can be performed using instrument ties by using the forceps to maintain tension while performing the floating knot (Figure 2G*) and stabilise the suture as it is tied on to the ICD to ensure it is tied tightly (Figure 2H*). A heavy size 0 or 1 nylon suture on a hand-held cutting needle 2
Fourteen junior surgical trainees attending a practical surgical training course were asked to secure an ICD on a cadaveric porcine model without direction as to which technique should be used; an assistant was provided. Once completed, the secured ICD was inspected and photographed. The depth of tube insertion (in cm) at the level of the skin was recorded. After securing the ICD, the two ends of the suture material were deliberately left long and a floating knot was tied to create a loop. Testing for robustness and potential for dislodgement was first performed by vigorously pushing and pulling on the ICD three times by the same examiner. Second, a Newton force metre (Force Tester with Newton Division, PCE Instruments UK Limited, Southampton, UK) was hooked through the loop created at the end of the suture to apply a constant ‘dislodging’ force of 50 N (equivalent to ∼5 kg) for 10 s to simulate expected ICD movements during combat casualty transfer. Dislodgement was then measured in centimetres (‘dislodgement score’) calculated as a sum of inward and outward movement when compared with the original depth of tube placement, for example 2 cm inward movement and 4 cm outward movement would be recorded as a dislodgement score of 6 cm. All trainees answered a short four-part questionnaire providing information on their previous experience with ICD insertion, whether they had received formal or informal teaching on how to secure ICDs, and finally whether they were aware of or had ever used the Jo’burg technique previously. The modified technique was then explained and demonstrated to the trainees with further 10 min allocated to practice the technique under supervision. Each trainee (with an assistant) then attempted to perform the technique unsupervised; the secured ICD was inspected to assess whether the modified Jo’burg technique had been performed correctly and was tested for security in the same way as before.
RESULTS Overall, 6/14 (43%) junior surgical trainees had never inserted an ICD prior to the study, 4 (29%) had intermediate experience with 1–9 insertions and 4 had inserted more than 10 ICDs. Almost 80% of the candidates had received formal or informal teaching on how to secure ICDs, but none of the 14 was aware Ablett DJ, et al. J R Army Med Corps 2017;0:1–5. doi:10.1136/jramc-2016-000744
Downloaded from http://jramc.bmj.com/ on September 18, 2017 - Published by group.bmj.com
Original article
Figure 2 The modified Jo’burg technique for securing an intercostal chest drain (ICD). (A) Insert the intercostal drain in the standard manner. (B) Using an appropriately robust suture, insert a horizontal mattress suture (incorporating the drain) with the extracorporeal loop positioned superiorly. Pull the two ends of the suture so that they are equal in length and remove the needle. (C) Place the tips of haemostatic forceps (held by an assistant) under the loop and tie the suture tightly inferior to the drain with a single throw. (D) Wrap both lengths of the suture tightly several times around the drain at the level of the skin. (E) Ensuring that tension is maintained, grasp both of the lengths of suture with the haemostatic forceps. (F) Again, ensuring that tension is maintained, pull the sutures under the loop. (G) Tie a floating knot approximately 2–3 cm from the skin level. (H) Wrap the sutures around the drain several times and tie tightly. Cut the suture and then apply a suitable air-tight dressing. Alternative technique (for medical personnel preferring to instrument tie). (G*) Hold the suture with the forceps, maintaining tension, while performing an instrument tie to create the floating knot. (H*) Hold the first throw of the suture with the forceps while instrument tying the suture on to the ICD.
of or had previously used the Jo’burg technique for securing an ICD. Table 1 shows the results of the pilot validation study showing individual trainee experience of ICD insertion, the chosen method during their first attempt and its corresponding dislodgement score. All trainees performed the modified Jo’burg technique correctly and the corresponding dislodgements cores are presented. The ‘Roman Sandal’ technique was used by 10/ 14 (71%) trainees on their first attempt with a median dislodgement score of 5 cm, compared with median 0 cm for the modified Jo’burg technique ( p10 0 >10 0 1–4 0 0 >10 0 1–4 5–9 >10
SSS; half stitches SSS; FRS SSS; FRS SSS; FRS SSS; FRS SSS; FRS Horizontal mattress; FRS SSS; FRS SSS; FRS SSS; floating single level at 2 cm Horizontal mattress; secured at skin level SSS; FRS SSS; FRS SSS; Single level tie at 2 cm
8 6 6 6 6 2 4 3 7.5 3 0 10 3 3
0 0 0 0 0 0 0 1 0 0 0 1 0 0
The two right columns demonstrate whether the modified Jo’burg technique was correctly performed at the second attempt with its corresponding dislodgement score. FRS, floating Roman Sandal technique; ICD, intercostal chest drain; SSS, Single skin suture.
0 cm), suggesting that without dedicated instruction of a robust, easily reproducible method of securing ICDs, the current methods used by junior trainees could lead to suboptimal acutephase care of the trauma patient. After the period of instruction and supervised practice, all trainees were able to perform the modified Jo’burg technique correctly resulting in securely inserted ICDs, suggesting it can be easily taught to junior staff and replicated to a satisfactory standard. The questionnaire answered by all the trainees after their first attempt highlighted the range of previous experience of ICD insertion with almost half of the trainees never having inserted an ICD before. This may well be in part due to regionalisation of UK trauma systems and major trauma centres within the last 7 years with only few trainees receiving adequate exposure to trauma training during their normal daily medical practice. This places even more emphasis on incorporating a standardised technique of ICD insertion into our military trauma courses for junior trainees. Furthermore, various military courses such as the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses, are aimed at established consultants (regular and reserve) with limited trauma experience or exposure in their routine practice and a standardised technique, adopted across the DMS, may also be useful. The relative lack of experience of ICD insertion also demonstrates that if any ‘new’ technique is deemed to be effective, it is likely to be a method that is easily reproducible and taught to junior medical personnel. There are limitations to this pilot study. First, the sample size of trainees taking part in the study is small and may not truly represent the target population of medical personnel deploying on military operations. However, the study was designed to evaluate trainees before and after instruction of the modified Jo’burg technique rather than comparing two groups that were not matched; in doing so, the small sample size of 14 subjects serve as their own control group (initial attempt). Second, the initial step for assessing robustness and dislodgement required the examiner to push and pull the ICD ‘vigorously’ three times. Although the same examiner was used throughout the study, a degree of variation will undoubtedly 4
exist in the forces used. Third, the Newton force metre used in this study had an analogue rather than a digital scale. This may result in greater measurement errors while also making it more difficult for the examiner to apply a constant force during the 10 s period. This pilot study can form the basis of future studies. Recruiting participants from the target population of military doctors may provide a more representative sample population and facilitate comparison between various groups such as trainees versus consultants and surgeons versus emergency physicians. Measuring the forces required to produce a certain amount of dislodgement (eg, 2 cm of outward displacement) may also eliminate the technical issues of producing a constant force over a fixed time period.
CONCLUSION This small pilot study shows that the modified Jo’burg technique can be easily taught to junior medical personnel and can be reproduced to a good standard, and we would advocate the use of this technique among both surgically and nonsurgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. Acknowledgements Mr John Taylor, course director of RCS(Eng) Surgical Skills in Emergency and Trauma. Contributors DJA: concept of study, performing the study, data collection, editing of manuscript. LN: data analysis, writing of manuscript. DC: performing the study, data collection, editing of manuscript. CGS and NRMT: editing of manuscript. Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed.
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The modified 'Jo'burg' technique for securing intercostal chest drains Daniel J Ablett, L Navaratne, D Chua, C G Streets and N R M Tai J R Army Med Corps published online June 26, 2017
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