An 80 year old man with air in the wrong place
An 80 year old man with advanced pulmonary fibrosis secondary to asbestos exposure presented to the emergency department with sudden onset shortness of breath and right sided chest and back pain. He was found to have a large, right sided pneumothorax. The patient was resuscitated and the on-call medical registrar inserted an underwater sealed chest drain. Its position was confirmed with a repeat chest radiograph.
Forty eight hours later, the junior doctor on call was asked to see the patient, who had severe face and chest pain with shortness of breath. He had not been vomiting or retching or undergone any further medical interventions and had not suffered any trauma. On examination, he looked unwell but could talk. The chest drain was in situ, but it was not swinging or bubbling and no leak was identified. His arms, chest, neck, and face were grossly distended, and there were subcutaneous crepitations