Identifying the site for intercostal catheter insertion in the emergency department: Is clinical examination reliable?

OBJECTIVE: To determine whether ED doctors, comprising both consultants and registrars, can accurately identify the 4th or 5th intercostal space (ICS), commonly used for intercostal catheter insertion. METHODS: An observational study was designed using a sample of ED doctors applying their clinical skills to a convenience sample of patients reflecting a heterogeneous mix of ED patients. Patients already receiving a CXR in our ED were examined by a registrar or consultant who placed a radiopaque marker on the patients' chest wall over the site they determined to be the 4th or 5th ICS. Consultant radiologists reported the marker's position from postero-anterior projection CXRs, and results were analysed comparing consultants with registrars, right to left hemithoraces and male to female patients. RESULTS: ED doctors participating in the present study placed the marker over the 4th or 5th ICS 36.2% of the time, with no significant difference between consultant and registrar groups, nor right or left hemithoraces. Accuracy was improved in female patients compared with male patients. CONCLUSION: Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.