2. Procedures in the Emergency Department

Procedures in the Emergency Department

Original Date: 02/2016 | Last Review Date: 07/2026
Purpose: To facilitate management of chest tube insertion procedures by residents and fellows in the ED.

Chest tube insertion procedures for adult patients (age 16 and over) will be divided as follows:

  • Stable chest tubes will be distributed equitably between trauma residents and emergency medicine residents and supervised by trauma faculty unless not available within 30 minutes and then chest tube insertion should proceed under EM faculty supervision.
    • Chest tubes on odd days will be performed by EM residents and on even days by trauma residents.
    • Odd/even day will be determined by the time of patient arrival to the MHH-TMC Emergency Department
    • Bilateral chest tubes will be split between the ED and trauma residents
  • Emergency chest tubes (required for hypotension, respiratory distress, or deemed emergent by the trauma faculty) are to be performed by the most experienced readily available provider, typically the trauma chief resident, fellow, or faculty, at the discretion of trauma faculty.
    • Non-level 1 patients requiring emergent chest tubes for hemodynamic instability should be upgraded to a level 1 activation immediately, and the trauma chief should be notified by phone (4-7055) while preparations are made for chest tube insertion without delay.
    • Pneumothorax or hemothorax identified on screening chest x-ray with hemodynamic normalcy should prompt urgent trauma consultation in accordance with urgent trauma consult criteria.
  • Residents performing the procedure should obtain informed consent, gather necessary supplies, and prepare the patient for chest tube insertion in a timely fashion (within 30 minutes) pending trauma faculty supervision.
  • EM faculty should be notified of chest tube insertion (and all other procedures) on patients still being primarily managed by the EM team.

FAST procedure will be divided as follows:

  • Level 1 trauma activations:
    • EM resident/intern will perform FAST during initial evaluation
    • Trauma resident may additionally perform FAST on odd days after stabilization of patient
    • EM faculty will oversee FAST performance and provide primary interpretation
  • For all other trauma patients the FAST will be performed by EM providers per normal operations

Trauma airway management:

  • Anticipated difficult or bloody airways will be managed by EM expertise
  • Stable intubations on select trauma patients can be managed with trauma/critical care fellow under direct EM faculty supervision