Goals and Plans: Turning Points for Success

Abstract

After emergency surgery, an obese patient with multiple injuries was transferred from the operating room to the surgical intensive care unit (SICU). His diagnoses included open fractures of the forearm and the femur, blunt chest trauma, a mild head injury, and multiple lacerations. The chest X-ray showed evidence of a lung contusion without any signs of fractured ribs or of a pneumothorax. On admission to the SICU the patient was adequately ventilated and his initial hemoglobin concentration was 11.5 g/dl. After 2 h of an uneventful course, the patient suddenly developed increasing peak airway pressures. Despite increasing the inspired oxygen concentration to 70%, the saturation continued to decrease and the patient remained hemodynamically instable. The resident physician in charge examined the patient and auscultated the lung and found decreased chest motion and decreased breath sounds over the right hemithorax. He assumed a pneumothorax and decided, without confirming his diagnosis by additional examinations and studies (e.g., chest X-ray), to perform a tube thoracostomy at once through an anterior axillary line incision.