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Wild Side of Medicine:
Chest Pain? Difficulty Breathing? Evacuate!

WMIBy Buck Tilton
Wilderness Medicine Institute of NOLS
Reprinted from The Leader, Summer 2000, Vol. 16, No. 3

It is a wilderness course, and you're happy to be a NOLS instructor, but not happy in the least about the young man, tall and thin, who is becoming more and more desperate for air. He was hiking with a heavy pack, sure, but he's in good shape. He leaped off a rock in the trail, that is all, not too far, and landed solidly. He complained of chest pain, a sudden pain, but you didn't think of it at first. Now, about an hour later, he can't continue the hike.

The pain is sharp, he says, and his pulse races at 110, strong and regular. Cool and clammy describes his skin. His anxiety increases almost as fast as yours. It is getting harder to breathe, he says, especially when he tries to take a deep breath.

What are you going to do? You keep the patient in a semi-reclining position since it seems to make breathing a bit easier. You decide to evacuate the young man. You decide wisely. The hospital diagnoses a spontaneous pneumothorax.

A weak spot on one of his lungs ruptured, and it happens most often to males who experienced a growth spurt. Air escaping the lung on inhalation and collecting in the chest outside the lung in the pleural space creates a closed pneumothorax. Over a period of time determined by the extent of the injury, the "dead air" in the chest cavity grows in size. With a stethoscope, you may hear diminished breath sounds on the affected side, beginning in the upper chest. If your hearing is acute, you may be able to hear diminished breath sounds on the affected side by pressing your ear against the patient's chest.

More often than not, a pneumothorax reaches a point where it gets no worse. But it can worsen until the patient is unable to breathe adequately, a condition known as a tension pneumothorax, one of the most life-threatening chest injuries. In a tension pneumothorax, air keeps leaking from the damaged lung, collecting in the pleural space until the lung on the affected side compresses to the size of a tennis ball. Air continues to leak out, compressing the heart, the great vessels, and even the other lung. Neck veins may bulge, sometimes called jugular vein distention or JVD, and the trachea may deviate toward the uninjured side. When the pressure of trapped air inside the chest reaches maximum tension, breathing stops.

Although circumstances could demand otherwise, it's best for the patient to be carried, preventing an increased work load on an already damaged lung. Do you know it's a pneumothorax? No. But any patient with sudden onset of chest pain and increasing difficulty breathing needs to be treated in a hospital.

Wilderness Medicine Institute
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