EMThoracostomy Insertion Lab

Resident learner portal • 36 residents • two cohorts

Thoracostomy Insertion Lab

A focused 45-minute resident circuit: field block, incision, controlled pleural entry, tube passage, drainage-system troubleshooting, and modified Jo’burg securement.

Start the circuit Open hosted teaching files
18
learners per cohort
6 × 3
pods
4:00
work + 0:45 move
1
model + Atrium
0–6 minSafety + anesthesia frame
6–10 minEntry + securement demo
10–38 minSix rotations
38–45 minQuiz + debrief

How this circuit works

One pod. Six stations. Every resident performs the high-risk steps.

Use three simultaneous lanes at Stations 1, 2, 4, and 6. Station 3 is the faculty-controlled model lane. Station 5 uses one drainage unit with rotating assembler, checker, and fault-finder roles.

Station 01 3 residents inject at once

Landmark + field block

  1. Mark the safe lateral insertion site before prep.
  2. State lidocaine concentration, mg/mL, local maximum, planned volume, and cumulative dose.
  3. Inject the skin, full tract, both bordering rib periostea, and just external to parietal pleura; aspirate before small aliquots.
  4. Extend the field slightly posteriorly or to adjacent levels only as taught locally; count every dose.
Ready to advance whenAll targets named; safe site maintained; aspiration and total dose verbalized.
Station 02 3 parallel cutting lanes

Incision + controlled tract

  1. Make a short transverse incision large enough for a finger and tube.
  2. Bluntly dissect through subcutaneous tissue with a curved clamp.
  3. Create a short controlled tract as taught locally and approach the intended interspace over the superior rib border.
  4. Keep the clamp under fingertip control; stop before pleural entry.
Ready to advance whenUsable incision, correct trajectory, no blind deep movement, sharps parked safely.
Station 03 Faculty lane • 3 rapid reps

Pleural entry + finger

  1. Advance the closed curved clamp over the superior rib border under fingertip control.
  2. Open only at the pleura with a controlled blunt spread; never use a trocar.
  3. Remove the instrument and insert a finger immediately.
  4. Confirm rib margins and pleural space; identify adhesions and lung proximity without blindly disrupting adhesions.
Ready to advance whenEach resident completes a controlled entry and immediate digital confirmation.
Station 04 3 open-tract lanes

Tube passage + depth

  1. Guide the tube beside the finger or through the confirmed tract.
  2. Direct the tube for the clinical goal while maintaining continuous control.
  3. Confirm every side hole, including the sentinel hole, is intrathoracic.
  4. State depth at skin and connect promptly to the drainage system.
Ready to advance whenTube controlled throughout; all fenestrations inside; depth stated aloud.
Station 05 1 unit • rotating team roles

Atrium + troubleshooting

  1. Identify the patient port, collection chamber, water seal, and suction control.
  2. Activate and set the device exactly per its IFU and the clinical order.
  3. Keep the unit upright and below the chest; trace the circuit from patient to chamber.
  4. Solve a kink or clamp, dependent loop, loose connection, or unexpected air leak.
Ready to advance whenClosed, patent system; correct setting; fault found without replacing the unit.
Station 06 3 residents tie at once

Modified Jo’burg + dressing

  1. Start with a horizontal mattress and long, equal limbs.
  2. Wrap both limbs together around the tube at skin level.
  3. Pass both beneath the external mattress loop, draw upward, and make a floating knot.
  4. Counter-wrap, tie without occluding the tube, then add an occlusive dressing and independent strain relief.
Ready to advance whenCorrect non-Roman-sandal sequence; tube secure and patent; dressing relieves traction.

The remembered tie

Modified Jo’burg / Soweto

This is not a Roman sandal. Both long mattress limbs travel together: wrap at skin level, pass under the external mattress loop, draw upward, make a floating knot, counter-wrap, and tie.

  1. AnchorHorizontal mattress; equal long limbs.
  2. WrapBoth limbs together around the tube.
  3. Under + upBoth limbs beneath the external loop, then upward.
  4. LockFloating knot, counter-wrap, tie; do not occlude.

Knowledge check

Rapid posttest

1Where should pleural entry occur?
2Which field-block targets matter?
3What immediately follows blunt pleural entry?
4What must be inside before fixation?
5After both Jo’burg limbs wrap together?

Evidence base

Core references

BTS Clinical Statement on Pleural Procedures JAMA Surgery chest tube review Modified Jo’burg drain fixation Chest-drain securement scoping review