A Good Clinician Leaves No Scar, No Fear — Just Relief.

Introduction

Every respiratory trainee remembers the first time they inserted a chest drain. Mine was in the small hours of a Cheshire night, the on-call registrar guiding my trembling hands as we relieved a spontaneous pneumothorax in a 19-year-old student. The procedure worked, but afterwards I wondered: did we do it the best way possible, or merely the way we had always done it? That question became the catalyst for the 2004-5 audit I carried out at Countess of Chester Hospital, later presented at the 2006 European Respiratory Society Congress. Re-examining those data nearly twenty years on—especially now that I practise in India where blunt-dissection, large-bore drains remain the default—feels more relevant than ever. Safe, comfortable care should be our priority, and guidelines exist for good reason. Yet our study showed that, even in a well-resourced UK district general hospital, we routinely deviated from the British Thoracic Society (BTS) recommendations, exposing patients to unnecessary pain, risk and anxiety.

What the guidelines say—and why they matter

The 2003 BTS document is crystal clear:

• Use the smallest effective drain (10–14 F)
• Insert in the “safe triangle” (mid-axillary line, 5th intercostal space)
• Employ full aseptic technique
• Provide adequate local anaesthesia (≤3 mg/kg lignocaine)
• Gain written consent and document the indication
• Perform a post-procedure chest X-ray on a specialist ward

Each step is evidence-based. Smaller drains reduce intercostal nerve irritation and late neuralgia; the safe-triangle approach avoids major vessels and the heart; generous local anaesthesia decreases pain scores and sympathetic surges; and proper documentation ensures medico-legal clarity and quality assurance.

Our findings: a mirror held to everyday practice

Over 12 months we identified 147 eligible cases (168 total; 21 penetrating traumas excluded). The headline numbers told their own story:

Only a third of drains were small-bore; the majority were 20 F or larger. Consent was usually verbal or absent, and in over half the cases we could not even determine the intercostal space used. These were not outliers—they were routine patterns replicated across medical, surgical and emergency departments.

Why large drains still dominate

Several forces conspire to keep 24–32 F drains in stock:

1. Cultural inertia—“big drain, big clot, big safety”
2. Resource perception—Seldinger kits cost more up front
3. Training gaps—junior staff rarely see Seldinger insertions during apprenticeships
4. Logistics—surgical wards may lack the stiff wires or dilators

Yet the BTS explicitly states that 10–14 F drains are “adequate for both pneumothorax and malignant effusion”. Subsequent randomised trials and meta-analyses (including the 2017 Cochrane review) show no difference in drainage failure rates, but significantly lower pain scores and shorter hospital stays with small drains. In other words, bigger is not better.

Moving the needle: from blunt dissection to Seldinger safety

The Seldinger technique—guidewire, serial dilatation, insertion of a flexible 12 F drain—offers multiple advantages:

• Smaller skin incision → less scarring
• Controlled entry → reduced risk of organ injury
• Better patient tolerance→ easier ambulation and physiotherapy
• Potential for outpatient management of spontaneous pneumothorax when combined with a Heimlich valve

Since relocating to India I have observed that most centres still favour the blunt-dissection (TROCAR) approach. Cost is the common defence: “A Seldinger set costs ₹3,500; a 28 F trochar drain ₹400.” But the true economic question is cost per quality-adjusted outcome. A reusable introducer set amortised over 50 cases, coupled with shorter length of stay, tips the balance. Where resources are constrained, simple bundles—chlorhexidine dressing pack, 10 ml lignocaine, 12 F multipurpose drain, and a basic wire—can be assembled for under ₹1,200, especially when purchased in bulk by hospital coalitions.

Five actionable steps for clinicians (and departments)

1. Adopt a standard operating procedure that mirrors BTS/ATS guidelines; laminate it, display it in procedure rooms
2. Run quarterly simulation sessions using inexpensive manikins; evidence shows skills decay without repetition
3. Bundle documentation into the electronic record: indication, size, site, local anaesthesia dose, aseptic checklist, X-ray timestamp
4. Start small, literally: for every new spontaneous pneumothorax or uncomplicated effusion, default to 12 F Seldinger unless contraindicated
5. Audit and feedback: present complication and pain-score data at morbidity meetings; visibility drives culture change

Patient-centred outcomes: what really counts

A 24 F drain may clear an effusion, but if the patient needs 180 mg of tramadol q8h and remains in hospital an extra two days, we have failed. Conversely, a 12 F drain inserted under generous local anaesthesia allows the young woman with catamenial pneumothorax to go home with a flutter valve and return to university lectures. She remembers how she felt, not what size drain we used. As William Osler reminded us, “The good physician treats the disease; the great physician treats the patient who has the disease.”

Conclusion

Our 2004-5 audit was a humble district-hospital snapshot, yet it reflected a national—and, I now appreciate, international—truth: guidelines only help when followed. Two decades on, the scene must change. Whether you practise in Chester or Chandigarh, the principles are identical: obtain consent, position carefully, anaesthetise generously, choose the smallest drain that does the job, and document every step. Seldinger technique should become the default, not the exception. If cost stands in the way, innovate, negotiate, recycle—but do not compromise on comfort or safety. Let us train the next generation to reach instinctively for the 12 F kit, not the 28 F trochar. Safe, comfortable, evidence-based care should be every patient’s right, and every clinician’s pride.

“Measure your success not by the number of drains you insert, but by the number of patients who forget you ever did.”