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Re: Nipples

Dear Editor,

Your article concerning junior doctors and their knowledge of chest drain insertion points is very interesting.

The exact diagram from the BTS guidelines (to which you refer) shows a greyed area where insertion is safe, it is as described in your article. However, the area that you have indicated as correct does not cover the entire triangle as described by the BTS guidelines - there is an area superior to the nipple yet in the zone that 24% were apparently incorrect in identifying as their target site.

I wholeheartedly agree with your conclusions that a large proportion of junior doctors are unaware of correct placement. Whether the education is best delivered by cardiothoracic surgeons or respiratory physicians is a moot point - on a practical level there are less cardiothoracic surgeons.

Another interesting question you might have addressed is that a large proportion of patients who receive an intercostal drain experience significant pain and consequently the guidelines suggest premedication. In my experience this is rarely given and in addition, people are inexplicably mean with their application of local anaesthesia.

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Re: Triangle of safety

Dear Editor,

We thank Dr Creagh-Brown for his interest in our article and comments.

We agree with the comments about figure 2, which is maybe misleading. The marks made by the juniors were judged with regard to the BTS guidelines as described in the article. Figure 2 is designed to illustrate where marks were made in relation to the triangle of safety (represented by the centre square). We agree that figure 2 does not show accurate boundaries of the safe area, but can assure Dr Creagh-Brown that the area he refers to was included in the safe area for marking purposes. The 24% in the lower centre square in figure 2 were all well below the nipple line and hence outside the BTS safe area.

We also agree with the comments regarding adequate analgesia in relation to chest drain insertion. In our experience this is poorly performed but was not assessed in our audit. Given that many of the juniors were unable to identify the correct anatomical landmarks, it is unlikely they would have mastered the difficult art of infiltrating local anaesthetic into the intercostals muscles.

With regards to training, we agree that respiratory physicians usually are well experience in intercostals drain insertion and could therefore provide local training. However, with the increased use of Seldinger drains by physicians their expertise with formal intercostals drains may diminish. We hope to incorporate formal teaching on the insertion of intercostal chest drains into the SHO education programme for both medical and surgical specialties and then repeat the survey in order to complete the audit cycle.

Overall we thank Dr Creagh-Brown for his interest in our article which we believe highlights an important issue in postgraduate medical education.

James Griffiths