A 50-year-old man walked into our Emergency Department after a high-speed road traffic collision. He was the driver. A solo rider. No eyewitnesses. No accompanying family. No medical records. He had sustained blunt trauma. His blood pressure was low. His eFAST was positive in abdomen and lung. The diagnosis seemed obvious.

Hemorrhagic shock. We moved quickly.

A pneumothorax was identified and an intercostal drain was inserted. The lungs appeared relatively clear on the initial ultrasound examination. The FAST examination demonstrated free intra-peritoneal fluid.

Blood products were requested immediately. As they should have been. A hypotensive trauma patient with a positive FAST should be presumed to be bleeding until proven otherwise (Bloom & Gibbons, 2019; Savoia et al., 2023). The first 2 units of blood started running. Then things became interesting.

Something Didn’t Fit

Instead of improving, the patient’s oxygen saturation began to worsen. The chest tube was functioning. The pneumothorax had been addressed. The repeat examination revealed no obvious procedural complication. Yet the patient was becoming increasingly hypoxic. A repeat lung ultrasound was performed. This time, symmetrical and diffuse bilateral B-lines had appeared.

Pulmonary edema.

After approximately one litre of blood. That wasn’t what we expected. This was supposed to be hemorrhagic shock. So why was he behaving like a patient with acute heart failure?

Looking Beyond The eFAST

A focused cardiac ultrasound was performed. The answer appeared within seconds. The left ventricle was severely impaired. Estimated left ventricular ejection fraction: approximately 20%. (later confirmed that he had underlying DCMP when family arrived with old records)

Suddenly the entire physiology made sense. The patient was indeed bleeding. The eFAST was not wrong. The shock was real. The blood was necessary. But he was also carrying severe underlying cardiac dysfunction that nobody knew about.

No previous records existed. No previous echocardiogram was available. No family member was present to provide a history. He arrived not only with traumatic injuries, but also with a failing heart. The blood products were treating one problem while simultaneously exposing another.

The Reality Of Trauma Care In LMICs

Cases like this are not rare. Many trauma patients in low- and middle-income countries arrive with years of undiagnosed or poorly managed cardiovascular disease.

Hypertension.
Ischemic heart disease.
Dilated cardiomyopathy.
Valvular pathology.
Heart failure.

Often untreated. Often undocumented. Often unknown even to the patient. Yet our trauma algorithms generally assume that hypotension in trauma equals hemorrhagic shock until proven otherwise.

Most of the time, that assumption is correct. But not always. And when it is incomplete, our resuscitation strategy may become incomplete as well.

eFAST Is One Of The Greatest Success Stories In Trauma

Before discussing alternatives, it is important to acknowledge what eFAST does exceptionally well. The extended Focused Assessment with Sonography in Trauma (eFAST) remains one of the most validated point-of-care ultrasound examinations in emergency medicine and trauma care (Netherton et al., 2019; Bella et al., 2025).

It rapidly identifies:

• Hemoperitoneum

• Hemopericardium

• Pneumothorax

• Hemothorax

These are diagnoses that directly influence immediate management decisions.

A systematic review and meta-analysis involving 75 studies and over 24,000 trauma patients demonstrated high specificity for identifying traumatic pathology, making eFAST an excellent rule-in tool in hemodynamically unstable trauma patients (Netherton et al., 2019).

For the question:

“Is traumatic bleeding or thoracic injury contributing to this patient’s shock?”

eFAST is extraordinarily effective. This is why it remains embedded within trauma protocols and ATLS-based assessment pathways worldwide (Bloom & Gibbons, 2019; Savoia et al., 2023).

Nothing in this article argues otherwise.

But eFAST Answers A Trauma Question

Not A Physiology Question. This distinction is important. eFAST tells us where blood may be accumulating. It tells us whether there is free fluid. It tells us whether there is a pneumothorax. It tells us whether there is a pericardial effusion.

What it does not tell us is:

• How well the heart is pumping.

• Whether the patient has severe cardiomyopathy.

• Whether the right ventricle is failing.

• Whether the patient can tolerate aggressive volume administration.

In other words:

eFAST identifies injuries. It does not fully characterize shock physiology. And these are not always the same thing.

Enter RUSH

The Rapid Ultrasound in Shock and Hypotension (RUSH) examination was designed to evaluate undifferentiated shock by assessing what ultrasound educators often call:

The Pump

• Cardiac contractility

• Pericardial effusion

• Right ventricular function

The Tank

• Volume status

• Inferior vena cava characteristics

• Pulmonary edema

The Pipes

• Aorta

• Major venous structures

(Estoos et al., 2019; Talayeh et al., 2018)

Unlike eFAST, which asks:

“Where is the bleeding?”

RUSH asks:

“Why is this patient in shock?”

The difference may seem subtle. At the bedside, it can be profound.

Does The Evidence Support Replacing eFAST?

No. And this is where we must be careful.

The current literature does not support replacing eFAST with RUSH in hypotensive trauma patients. There are no high-quality comparative studies demonstrating that routine RUSH examination improves mortality, accelerates definitive interventions, or provides superior outcomes compared with eFAST alone in trauma populations (Stickles et al., 2019; Talayeh et al., 2018).

In fact, trauma-specific evidence remains substantially stronger for eFAST (Netherton et al., 2019; Bella et al., 2025).

A prospective study of 100 unstable polytrauma patients reported a sensitivity of 94.2% and diagnostic accuracy of 95.2% for RUSH when compared with CT findings and final diagnoses (Elbaih et al., 2018).

These findings are encouraging. But they do not establish superiority over eFAST.

At present, the evidence suggests that RUSH broadens the differential diagnosis of shock rather than replacing established trauma ultrasound pathways (Elbaih et al., 2018; Berger et al., 2024).

Maybe We Are Asking The Wrong Question

The debate should not be:

eFAST versus RUSH.

Perhaps the more useful question is:

Should selected hypotensive trauma patients receive a rapid RUSH-style extension immediately after eFAST?

Particularly when:

• The physiology appears disproportionate to the injuries.

• The patient is older with unknown medical history.

• Shock persists despite apparently appropriate resuscitation.

• Respiratory status worsens unexpectedly.

• There is concern regarding cardiac reserve.

• The response to blood products is not what we anticipated.

In these situations, a 30-second cardiac and lung ultrasound examination may provide information that fundamentally alters our understanding of the patient. Not necessarily the diagnosis. But certainly the physiology.

Returning To Our Patient

Would identifying an ejection fraction of 20% before transfusion have stopped us from giving blood?

Absolutely not. The patient was hypotensive. The patient was FAST positive. The patient was bleeding. Blood products were indicated.

But would it have changed how we administered those blood products?

Probably.

Would it have changed our monitoring strategy?

Almost certainly.

Would it have made pulmonary edema less surprising?

Definitely.

Would it have prompted earlier consideration of Surgical interventions, vasopressors, invasive monitoring, or damage-control resuscitation strategies tailored to limited cardiac reserve?

Possibly.

And perhaps that alone is enough reason to look beyond the abdomen.

The Frontline Takeaway

eFAST remains the cornerstone of ultrasound assessment in hypotensive trauma. The evidence supports it. The guidelines support it. The outcomes support it. But trauma patients are more than their injuries.

Especially in resource-limited settings, they often arrive carrying years of undocumented disease alongside their traumatic pathology.

A positive FAST explains where blood may be accumulating. It does not explain how the patient will respond to our resuscitation. The next evolution in trauma ultrasound may not be replacing eFAST with RUSH. It may simply be remembering to look at the heart before assuming that every shocked trauma patient needs the same resuscitation strategy. Sometimes the most important finding is not the free fluid. Sometimes it is the ventricle struggling silently beside it.

Pulse Checks and Reflections

1. Guidelines Are Frameworks, Not Replacements for Clinical Judgment

Trauma guidelines exist to standardize care, reduce variability, and ensure that life-threatening injuries are identified and treated rapidly. They provide an essential framework, particularly in high-acuity situations where decisions must be made quickly.

However, no guideline can account for every patient, every physiology, or every clinical context. As clinicians gain experience, the challenge is not knowing when to follow guidelines, but recognizing when a patient’s physiology requires us to look beyond the algorithm while still respecting its principles.

In this case, the guideline-directed approach was appropriate. The experience simply reinforced the importance of continuously reassessing whether the patient’s response matches our expectations.

2. Looking Beyond eFAST Is Not Necessarily Departing From Trauma Principles

This reflection is not an argument against eFAST, nor is it a proposal to replace established trauma protocols.

Rather, it highlights the potential value of extending the ultrasound examination to include a rapid assessment of cardiac function and volume status in selected hypotensive trauma patients.

A RUSH-style examination incorporates the core components of eFAST while adding information about the heart and the patient’s overall shock physiology. The goal is not to change the diagnosis of hemorrhagic shock, but to better understand how a patient may tolerate ongoing fluid or blood product administration.

In some cases, identifying limited cardiac reserve early may allow clinicians to anticipate complications, tailor resuscitation strategies, and expedite definitive hemorrhage control when appropriate.

3. Trauma Patients Do Not Always Present With Trauma Alone

In many low- and middle-income countries, patients frequently arrive without prior medical records, medication lists, or accessible health information.

Significant comorbidities often remain undiagnosed or poorly documented. Conditions such as heart failure, ischemic heart disease, chronic kidney disease, and valvular pathology may coexist with traumatic injuries and influence the patient’s response to resuscitation.

While trauma may be the reason for presentation, underlying physiology often determines how that patient responds to treatment.

This case served as a reminder that understanding the patient sometimes requires looking beyond the injury itself.

4. A Personal Change in Practice

This case has not changed my belief in the value of eFAST or the principles of trauma resuscitation.

What it has changed is my threshold for performing a brief cardiac assessment in hypotensive trauma patients, particularly when the patient’s age, physiology, or response to treatment raises questions. Not because every patient requires it. Not because guidelines are inadequate. But because occasionally, a 30-second look at the heart may reveal information that helps us better understand the physiology in front of us. And sometimes, that additional piece of information can make all the difference.

"Trauma may explain why the patient is here. Physiology often explains how they will respond to what we do next."

References

1. Bella F, Bonfichi A, Esposito C, et al. Extended Focused Assessment with Sonography for Trauma in the Emergency Department: A Comprehensive Review. J Clin Med. 2025;14.

2. Berger M, Hussain J, Anshien M. RUSH to the Diagnosis: Identifying Occult Pathology in Hypotensive Patients. Clin Pract Cases Emerg Med. 2024;8:379-380.

3. Bloom BM, Gibbons R. Focused Assessment with Sonography for Trauma (FAST). 2019.

4. Elbaih A, Housseini A, Khalifa M. Accuracy and outcome of rapid ultrasound in shock and hypotension (RUSH) in Egyptian polytrauma patients. Chin J Traumatol. 2018;21:156-162.

5. Estoos E, Nakitende D, Bhimji S, Cole J. Diagnostic Ultrasound Use in Undifferentiated Hypotension. 2019.

6. Netherton S, Milenkovic V, Taylor MR, Davis P. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019.

7. Savoia P, Jayanthi SK, Chammas M. Focused Assessment with Sonography for Trauma (FAST). J Med Ultrasound. 2023;31:101-106.

8. Stickles S, Carpenter C, Gekle R, et al. The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis. CJEM. 2019.

9. Talayeh R, et al. Early Protocolized Bedside Ultrasound in Shock: Renal Function Improvements and Other Lessons Learned. Int J Crit Care Emerg Med. 2018.

He was thin, malnourished, and battling aplastic anemia. His hemoglobin was critically low. His platelet counts were dangerously reduced. Earlier imaging had revealed a small intracranial bleed—a consequence of the severe thrombocytopenia. Fortunately, he was awake, talking, and neurologically intact.

Beside him sat his grandmother. She looked tired. More than tired—angry. At first, it was easy to mistake that anger for hostility. Around midnight, the platelets arrived. Within minutes, voices began rising from the bedside.

“Why are you giving him this yellow fluid?”

“He has a blood disease.”

“He needs blood.”

“No one is listening to me.”

My junior resident and the nursing staff tried to continue the transfusion, but the grandmother resisted. At one point, she removed the transfusion herself. The situation quickly became tense.

From the healthcare team’s perspective, the treatment plan was straightforward.

The child had active bleeding inside his skull. Platelets were urgently needed to reduce the risk of further hemorrhage. Red blood cells would also be transfused, but in carefully calculated doses appropriate for his weight. Giving multiple units rapidly was neither safe nor necessary.

Medically, the plan made perfect sense. But there was a problem. Nobody had explained it to her. To understand what was happening, we need to step away from the monitor and look at the person sitting beside the bed.

This grandmother had become everything for that child.

The burden of a chronic blood disorder had slowly pushed everyone else away. She was the one accompanying him to hospital visits, standing in outpatient queues, arranging previous transfusions, and somehow earning enough to keep life moving. Over time, she had learned one thing:

Whenever her grandson became weak, he needed blood.

That was the pattern she understood. That was the reality she had lived. Now she was being told that the doctors were refusing to give blood and were instead hanging a yellow-colored bag she had never seen before. From her perspective, it looked as though the people caring for her grandson were ignoring the obvious.

Her anger was not opposition. It was fear. It was exhaustion. It was love trying to protect someone when it did not have enough information to understand what was happening. When we sat down and explained the situation, everything changed.

We explained that her grandson was bleeding inside his brain. We explained the role of yellow fluid (platelets). We explained why platelets were more urgent than red blood cells at that moment. We explained why blood transfusions had to be given carefully slowly and safely. Most importantly, we explained the plan.

For the first time that night, she could see what we were seeing. The resistance disappeared. The arguments stopped. She agreed to treatment.

The next morning, she thanked the team. The art of medicine had not changed.

The communication had. As we grow older in this profession, many of us realize that some of the biggest challenges in medicine are not clinical.

They are human.

Families enter emergency departments carrying fear, financial stress, exhaustion, grief, and uncertainty. They are suddenly surrounded by unfamiliar equipment, unfamiliar medications, unfamiliar decisions, and unfamiliar language. When they don’t understand what is happening, that fear often comes out as anger.

Sometimes we label them as difficult. Sometimes we become frustrated. Sometimes, in the exhaustion of a busy shift, we forget that they are trying to make sense of a world that is completely foreign to them.

Communication is often viewed as a soft skill. In reality, it is a clinical skill.

‘Good communication prevents conflict.
Good communication improves adherence to treatment.
Good communication builds trust.
Good communication protects patients, families, and healthcare workers alike.’

In another setting, with a different relative, this encounter could easily have escalated into verbal abuse or even violence. The ingredients were all there: fear, misunderstanding, emotional distress, and a crowded emergency department.

The solution was not a better transfusion. It was a better conversation.

This was not a failure of an individual doctor, nurse, or family member. It was a reminder of a system under pressure, where exhausted clinicians care for more patients than time allows and where explanations are often sacrificed to urgency. Yet those few minutes spent explaining may be among the most important interventions we perform. Because medicine is not only about making the right decision.

It is about helping others understand why that decision is right. Sometimes the difference between conflict and cooperation is not another test, another drug, or another procedure. Sometimes it is simply a chair pulled beside a worried grandmother and a conversation she desperately needed to hear.

Pulse Checks and Reflection

Before we ask why a family member is angry, perhaps we should first ask:

‘What important piece of the story do they not know yet?

A grandmother saw a yellow bag.
We saw platelets.
She saw delay in correct treatment.
We saw protection.
She saw danger.
We saw treatment.
Between what she saw
and what we knew
stood only a conversation.
And sometimes,
the distance between conflict and trust
is no greater than that.’

On this Emergency Medicine Day, let me tell you a recent story from a peripheral center where I am currently working — a story that reminded me why I chose this specialty, and why, despite the chaos, exhaustion, uncertainty, and emotional burden, I remain deeply proud of what we do as Emergency Physicians. Because Emergency Medicine is not merely about treating disease.

It is about standing beside human beings during the worst hour of their lives, making critical decisions before certainty arrives, and fighting for patients who still have a chance to come back from the edge. This is a story from a peripheral center where I am currently posted. Not a large tertiary-care resuscitation bay. Not a perfectly staffed academic unit. Just one of the many frontline centers in our healthcare system where critically ill patients arrive first — often before systems are ready for them.

“She had finally won.”

For almost a decade, cancer had dictated the rhythm of her life.

Hospital corridors.
Chemotherapy cycles.
Surgical scars.
Follow-up scans.
The quiet anxiety before every report.

Cervical cancer had taken years from her life, but not her fight. And then, fifteen days before I met her, she heard the words every cancer patient waits for:

No metabolically active lesion.

Her PET-CT showed remission.

For her family, it was not merely a report. It was resurrection. But medicine has a cruel way of reminding us that survival is rarely linear. Seven days before arriving to our Emergency Department, she had noticed swelling in her left leg. She visited the outpatient department of our peripheral center, where a lower limb ultrasound was advised.

The scan date was given three days later.

Nobody was wrong.
Nobody was careless.
Just another ordinary delay inside an overburdened healthcare system.

Three days later, she returned. She walked into the ultrasound room alive. While lying down during the scan, she suddenly became breathless. The scan was somehow completed. But now she could barely complete sentences. She was visibly short of breath and rapidly deteriorating. She was rushed into our Emergency Department.

When she arrived, her blood pressure was not recordable.
Her oxygen saturation hovered in the 80s.
Her body had already entered shock.

The monitors were connected. IV lines secured. The first fluid bolus started.

The venous blood gas returned:

pH: 6.7
Lactate: 15
Hco3 = 6
pCo2 = 19

Her body was failing faster than words could describe it. We performed Point-of-Care Ultrasound (POCUS). The right atrium was grossly enlarged, right ventricle ballooned against a struggling septum. McConnell’s sign stared back from the screen.

At that moment, the diagnosis became painfully clear. Massive pulmonary embolism.

A clot had likely traveled silently from the swollen leg she noticed days ago, into the pulmonary circulation, and now her right heart was collapsing under the pressure.

Most textbooks make the next step sound straightforward.

“Give thrombolysis.”

But medicine at the bedside is never written like textbooks. Because now came the real problem. We were functioning in a peripheral center. No unit was willing to admit a post-thrombolysis unstable patient in this centre, before even documenting they were told not to admit the patient. And she was too unstable to survive transfer elsewhere.

There are moments in Emergency Medicine where the physician stands alone between protocol and reality.

This was one of them. Giving thrombolysis carried enormous risk. Not giving it would almost certainly kill her. And then came the hardest part of Emergency Medicine — not the procedures, not the drugs, not the ultrasound.

The conversation.

I had to sit beside her daughter and explain that the mother who had just survived cancer was now standing at the edge of another catastrophe.

I explained the diagnosis.
The risks.
The bleeding possibility.
The uncertainty.
The fact that we did not have the ideal system support around us.
The fact that shifting her in this condition might itself become fatal.

I still remember the silence after that conversation. The daughter’s eyes filled with tears. Fifteen days ago, they celebrated remission. Now they were discussing whether her mother would survive the next few hours. Emergency physicians witness human beings at the exact moment life changes direction.

Not in conference halls.
Not in polished discharge summaries.
But in overcrowded resuscitation bays, where decisions must be made before certainty arrives.

We minimized fluids after identifying the failing right ventricle.
Noradrenaline was started.
Vasopressin followed.
Anticoagulation initiated.
Nebulized nitroglycerin was prepared.

And finally, after informed consent, the thrombolytic infusion began. At that point, another decision had to be made. Should we intubate?

Many critically ill patients eventually require airway support, but in massive pulmonary embolism, induction and positive pressure ventilation can precipitate cardiovascular collapse. She was compensating for her acidosis still — and we decided to maintain a very high threshold for intubation.

So we waited. Watched closely. Adjusted vasopressors. Repeated assessments. Managed physiology minute by minute.

Slowly, she began improving. The blood pressure returned. The oxygenation improved.
The storm inside her pulmonary circulation began to settle. And sitting there afterward, exhausted in that resuscitation room, I kept thinking:

This is why Emergency Medicine exists.

Emergency Medicine is not merely triage.
It is not just “initial management.”
It is not a transit lounge before “real specialties” take over.

Emergency Medicine is the specialty of the first hour, the resucitation, the time.

The hour where diagnosis is uncertain. Where systems are imperfect. Where protocols collide with reality. Where families collapse emotionally. Where physiology deteriorates by the minute. Where someone must integrate ultrasound, resuscitation, communication, pharmacology, risk-benefit analysis, airway judgment, hemodynamics, and ethics — simultaneously.

That someone is the Emergency Physician.

Emergency Medicine also exists for another uncomfortable reality in healthcare. It exists when diseases stop fitting neatly into one specialty. When the patient has shock, respiratory failure, metabolic acidosis, hemodynamic collapse, and an unclear disposition — all at the same time. It exists when multiple systems are failing together, and multiple departments hesitate because the patient belongs partially to everyone, and completely to no one. It exists when nobody wants to take responsibility first. It exists when a patient has nowhere else to go.

When transfer is impossible. When admission is uncertain.
When the patient is denied from everywhere else because they are “too unstable,” “too high-risk,” or “too complicated.”

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That is when the Emergency Department becomes more than a physical space. It becomes the safety net of the healthcare system. And the people holding that net together are Emergency Physicians. Because at the core of Emergency Medicine lies one simple responsibility:

To resuscitate the patient who made it to the hospital in time. To pull them back from the edge of physiological collapse. To bring them out from the doom of illness before the body crosses a point where recovery is no longer possible.

That responsibility exists regardless of whether the diagnosis is clear. Regardless of whether a bed is available. Regardless of whether another department has accepted the patient. Regardless of how chaotic the environment becomes.

Our first instinct is always the same:

Stabilize.
Resuscitate.
Buy time for life.

And the strange thing about Emergency Medicine is that most patients never truly remember us afterward. They move to wards, ICUs. Then discharge summaries.
Then follow-up clinics. Then life slowly returns to normal.

The emergency department becomes just a blurred chapter in their memory. And honestly, that is okay. Because our work was never about recognition. But sometimes, families remember. Sometimes they see the physician running from one crashing patient to another, handling chaos while still trying to reassure a frightened daughter standing beside her critically ill mother. At the end of that shift, after hours of vasopressors, thrombolysis, difficult decisions, and uncertainty, her daughter came to me and simply said:

“Thank you, doctor.”

It was a small moment. But after one of the heaviest shifts, it made my entire day. Because in that moment, someone understood what Emergency Medicine truly is.

Not glamour.
Not heroism.
Not dramatic television scenes.

Just human beings trying to hold life together in its most fragile moments. This is why we exist. Qualified Emergency Physicians are not a luxury for tertiary hospitals.
They are a necessity for every medical college, every emergency room, every frontline center where critically ill patients first arrive.

Because salvageable patients do not always reach ideal systems.

Sometimes they reach peripheral centers.
Sometimes they arrive before specialists.
Sometimes they deteriorate in front of junior doctors with minimal support.
Sometimes the difference between life and death is whether someone in that room understands shock physiology well enough to act before certainty appears.

Emergency Medicine exists for those moments. Not every patient can be saved. But many can be salvaged if the right decisions are made early enough. And that is what Emergency Physicians are trained to do:
make critical decisions inside physically chaotic, emotionally overwhelming, resource-limited environments — while time itself is collapsing around the patient.

This is where Emergency Medicine comes in.

At the frontline.
Before clarity.
Before admission.
Before certainty.

Sometimes, before death.

It was 2:30 AM in the Emergency Department.

A middle-aged man with metastatic lung malignancy arrived breathless, exhausted, and unable to complete sentences. His chest radiograph showed a massive right pleural effusion with near-complete white-out of the hemithorax. Bedside ultrasound confirmed a large anechoic effusion with passive lung collapse.

His oxygen saturation improved slightly with non-invasive support, but he remained uncomfortable. The decision was made for therapeutic thoracentesis.

The procedure went smoothly.

Ultrasound-guided.
Single attempt.
No cough.
No obvious complication.

About 1.2 liters of straw-colored fluid was drained. The patient immediately reported relief.

And then came the post-procedure chest X-ray.

“Doctor… there’s a pneumothorax.”

Suddenly, the room shifted.

The reflex in Emergency Medicine is almost automatic:
Pneumothorax = chest tube.

But this wasn’t that kind of pneumothorax.

This was pneumothorax ex vacuo.

The Diagnostic Trap in the ED

One of the hardest things in Emergency Medicine is resisting the urge to treat the image instead of the patient.

The X-ray showed a moderate pneumothorax.
But the patient?

• Comfortable

• Hemodynamically stable

• Improved dyspnea

• No worsening hypoxia

• No respiratory distress

The physiology and the radiology were telling different stories.

That mismatch matters.

What Actually Happened?

In pneumothorax ex vacuo, the issue is not accidental lung puncture.

The real problem is an unexpandable lung.

Usually this happens because of:

• Malignant pleural disease

• Trapped lung from chronic inflammation

• Endobronchial obstruction

• Visceral pleural restriction

The pleural effusion is often not the primary disease — it is a consequence of chronic negative pleural pressure from a collapsed lung. When fluid is removed, the lung fails to re-expand. A transient pressure gradient develops, allowing air to enter the pleural space and “fill the vacuum” (Farkas, 2014; Heidecker et al., 2006).

That air is not under tension.
It is not rapidly progressive.
And most importantly — a chest tube usually does not fix it.

So What Should We Actually Do?

This is where Emergency Medicine becomes less procedural and more physiological.

The ideal management depends on one simple principle:

Treat the patient, not the radiograph.

If the patient is:

• Hemodynamically stable

• Maintaining oxygenation

• Clinically improving after thoracentesis

• Without signs of tension physiology

…then the best treatment is often:

Observation.

Not another procedure.

Not reflex chest tube insertion.

Not panic.

Why Observation Is Usually Better

Pneumothorax ex vacuo is fundamentally different from traumatic or spontaneous pneumothorax.

The lung is unable to expand because of underlying pathology. Draining the pleural space with an intercostal drain does not solve the primary issue. Instead, it may expose the patient to:

• Persistent air leak

• Procedural pain

• Infection risk

• Repeated interventions

• Prolonged hospitalization

Heidecker et al. (2006) and Huggins et al. (2010) demonstrated that these pneumothoraces are usually benign and rarely progress to tension physiology.

In many cases, the pneumothorax remains stable or gradually gets replaced again by pleural fluid over time.

Then What Is the Treatment?

The real treatment is identifying and managing the cause of the trapped or non-expandable lung.

Depending on the etiology, management may involve:

1. Treating Endobronchial Obstruction

If due to a central airway lesion:

• Bronchoscopy

• Tumor debulking

• Stenting

• Oncology-directed therapy

may allow lung re-expansion.

2. Managing Malignant Trapped Lung

In malignant disease:

• Indwelling pleural catheter

• Symptom-guided drainage

• Palliative management

are often more appropriate than repeated thoracenteses.

3. Surgical Decortication

In selected patients with fibrous visceral pleural restriction and good functional reserve:

• VATS decortication

• Surgical pleural peel removal

may restore lung expansion.

But this is rarely an ED decision.

4. Supportive Care

Most ED patients only need:

• Observation

• Oxygen if required

• Monitoring

• Repeat imaging only if clinically indicated

• Specialty follow-up

And often, reassurance.

When Should We Worry?

Observation is appropriate only if the patient remains clinically stable.

Red flags that should prompt reconsideration include:

• Worsening respiratory distress

• Hemodynamic instability

• Progressive hypoxia

• Rapid enlargement on imaging

• Features suggestive of true procedural lung injury

Because not every post-thoracentesis pneumothorax is ex vacuo.

Clinical context matters.

The Ultrasound Era

Traditionally, any pneumothorax after thoracentesis was considered procedural injury.

But with modern ultrasound guidance, true traumatic pneumothorax has become less common. Pneumothorax ex vacuo is now increasingly recognized as a distinct physiological entity rather than a procedural complication (Farkas, 2014).

Not all post-procedure pneumothoraces are created equal.

And that distinction changes management entirely.

Pulse Checks and Reflections

What stayed with me after this case wasn’t just the physiology of pneumothorax ex vacuo — it was the emotional reality of practicing medicine within hierarchy.

Sometimes you stand in a centre of excellence, surrounded by experienced clinicians, yet still feel the tension between evidence and authority.

The patient was stable.
The physiology made sense.
The literature supported observation.

And still, the reflex around the room was:
“Insert a chest tube.”

One difficult truth in medicine is that knowledge and authority do not always evolve at the same pace.

Medicine changes constantly. Protocols evolve. Evidence updates itself. What was once standard teaching may later become outdated practice. That is why no opinion — no matter how senior or widely accepted — should replace clinical reasoning.

That night reminded me that medicine demands humility from everyone, not just juniors.

Because even respected clinicians can occasionally be wrong.
And sometimes the quietest person in the room may notice something important.

Later, when the specialty team agreed with conservative management and discharged the patient, it reinforced an important lesson:

Always return to the patient.
Not the panic.
Not the image.
Not the hierarchy.

In moments of uncertainty, it helps to anchor yourself in physiology and evidence. Revisit the teaching. Cross-check the literature. Discuss with people you trust. Seek another perspective if something does not feel right.

Not to challenge authority for ego —
but to protect patients from unquestioned assumptions.

And when disagreement with a senior becomes necessary, it should be constructive, respectful, and preferably private.

Not:
“You’re wrong.”

But:
“Could this represent something else?”
“Should we reconsider this based on the clinical picture?”
“I read newer evidence suggesting observation may be reasonable here.”

That is not disrespect.
That is safe medicine.

The challenge is learning how to balance humility with independent thinking — respecting experience without surrendering your ability to reason critically.

Because medicine is too complex for blind obedience and too human for absolute certainty.

Acute Medicine eventually teaches you that good clinical practice is not only about knowing when to intervene.

It is also about recognizing when restraint, observation, and thoughtful questioning are the better decisions.

And at the end of the day, your responsibility is not to hierarchy.

It is to the patient.

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References

• Farkas J. Pneumothorax ex vacuo: Post-thoracentesis pneumothorax in the ultrasound era. 2014.

• Heidecker J, Huggins JT, Sahn SA, et al. Pneumothorax ex vacuo. Chest. 2006.

• Huggins JT, Sahn SA, Heidecker J, et al. Characteristics of trapped lung and pneumothorax ex vacuo. Chest. 2010.

Recently, I watched Michael.

What stayed with me wasn’t just the story — it was the reminder of how deeply our childhood experiences shape the way we see the world.

The same sentence.
The same event.
The same silence.

Can mean completely different things to two different people.

Because all of us are interpreting life through memories, fears, insecurities, love, trauma, hope, and experiences we carry from years before.

Working in the Emergency Department and acute care constantly reminds me of this.

Sometimes a patient is not “angry.” They are scared.
Sometimes a relative is not “difficult.” They are exhausted from months of caregiving.
Sometimes chronic illness doesn’t just damage the body — it changes how a person sees themselves, their future, and even their worth.

Acute care medicine teaches you that before treating disease, you first have to understand the human being experiencing it.

And maybe outside medicine too, we forget this often.

We judge reactions without knowing histories.
We hear words without understanding the wounds behind them.

It makes me grateful — for health, for perspective, for the privilege of still having time to live, learn, improve, and connect.

If this resonates with you, I’d love to hear your thoughts or experiences too.
What’s something that shaped the way you perceive life today?

- Dr Arihant Jain, MD