Abstract:
Devices and methods are disclosed for achieving chest drainage in humans or other animals. Chest drainage is often required following traumatic injury or surgery. The devices and methods disclosed herein are especially useful in the emergency, trauma surgery or military setting. The devices utilize a chest tube with a cutting distal end and a central blunt trocar. The blunt trocar or obturator shields the sharp cutting distal end of the chest tube until controllably retracted. Once the blunt trocar or obturator is retracted, the chest tube is advanced out through its sterile, protective package and into the patient. The blunt trocar is advanced back into its position to shield the sharp tip of the chest tube during patient insertion. The chest tube also includes a hold-down mechanism that is created by an adhesive seal to the patient&#39;s chest and ribbons or straps that are wrapped around the chest tube once it is correctly positioned. The straps include adhesive ends to grip the chest tube once the straps are in place.

Description:
This application claims priority benefit under 35 USC § 119(e) from U.S. Provisional Application No. 60/477,110 filed Jun. 9, 2003, and U.S. Provisional Application No. 60/415,188 filed Sep. 30, 2002. 
    
    
     FIELD OF THE INVENTIONS 
     The inventions described below relate the fields of general surgery, cardiothoracic surgery, trauma surgery, combat medicine, and emergency medical services. 
     BACKGROUND OF THE INVENTIONS 
     Chest drainage tubes are flexible tubes that are placed into a patient&#39;s chest cavity to allow for drainage of fluids following trauma or surgery. These chest tubes have one or more holes at the distal end through which the fluid is evacuated from the chest cavity into the lumen of the chest tube. The proximal end of the chest tube includes connectors to allow for passage of the drained fluids from the lumen of the chest tube into a collection device or apparatus. The chest tubes or collection apparatus typically include features to prevent backflow of air into the chest cavity, thus preventing pneumothorax. These backflow prevention features include shutoff valves and duckbill valves. Typical collection apparatus comprises gravity fed drains or vacuum or pump powered drainage mechanisms. 
     Chest tubes are typically placed into a patient with a stiff trocar mounted to the internal lumen. The trocar is stiff, relatively pointed at the distal end, and allows for advancement of the flexible chest drainage tube into an incision in the chest wall. The stiff, pointed trocar is useful for initial insertion of the chest tube but becomes a dangerous instrument once the chest tube is advanced below the level of the ribs. Use of such internal trocars is not appropriate for non-physician insertion because of the inherent danger of heart or lung perforation. 
     Maintenance of sterility has always been problematic with chest tubes. Placement of a chest tube, especially in the emergency setting, requires sterile scrub of the incision area and incision into the chest wall with sterile instruments. These incisions are, understandably, difficult to perform aseptically in the field, where the insertion site may be bloody, dirty or otherwise contaminated. In addition, maintenance of sterility in the area of chest tube penetration into the chest has been difficult as has been the ability to hold the chest tube in position once it has been introduced into the patient. The use of surgical gloves to maintain sterility becomes problematic since the gloves become contaminated quickly in the typical field environment. 
     New devices and methods are needed to permit rapid placement of chest tubes by less trained individuals in contaminated environments. In addition, improved devices and methods of maintaining sterility at the chest tube wound site and holding the chest tube in place are needed. 
     SUMMARY OF THE INVENTION 
     This devices and methods described herein provide for placement of chest tubes in contaminated environments using rapid deployment techniques, for maintaining sterility at the penetration site on the patient&#39;s chest where the chest tube emerges, and for improved methods of holding the chest tube in place. The present invention is a chest tube that is provided with a double aseptic package that maintains sterility and cleanliness of the chest tube in contaminated environments. The chest tube includes a cannula with a sharpened distal end and a blunt trocar or nose cone that selectively shields or exposes the sharpened distal end. 
     In another embodiment, a region on the chest tube is configured to allow for maximum friction while gripping the chest tube through the package material. In another embodiment, a region on the packaging is fabricated from gripping material to facilitate pushing the chest tube inside the packaging. The region on the packaging optimized for gripping the chest tube is optionally fabricated from elastomeric material to facilitate moving the chest tube inside and relative to the inelastic package. In another embodiment, the blunt trocar itself is shaped so as to penetrate the package without the need of a separate sharp tip. This blunt trocar is also suitable for blunt dissection into the chest wall once the initial incision has been completed. 
     The chest tube may further include a malleable region along part or all of its length to facilitate bending of the chest tube into a pre-determined shape. The use of a curved or bent shape on the part of the chest tube facilitates placement beneath the ribs but above the lungs and heart. 
     Another feature of the invention is a patch, disc, plate or membrane of adhesive-faced impermeable material that is adhered to the site where the wound will be created in the chest wall. The patch may also be coated with materials that have disinfectant properties. The patch also includes straps disposed, for example, in a starburst pattern. Once the site has been swabbed with disinfectant, the disc of material is adhesively placed on the skin at the site of the incision. The incision is now made through the patch of material. This patch serves as a sterile barrier following placement of the chest tube. The straps serve to hold onto the chest tube to maintain its position once placed. The straps are wrapped around the chest tube and adhesively affixed to the shaft of the chest tube after placement, thus securely holding the chest tube to the disc, which is affixed to the chest wall of the patient. The patch is optionally pre-mounted to the chest tube inside the package. In this embodiment, the chest incision is performed prior to attachment of the patch to the patient. In another embodiment, the disc is integral to the inner packaging material so that once the outer packaging material is removed, the patch may be immediately placed against the chest over the region of the incision. 
     In another embodiment of the invention, a chest tube is designed with an integral tip that permits the chest tube to be advanced out of the package by forcing a fenestration in the package wall or seal. The integral tip may be a cutting member that is selectively exposed by the operator and then retracted following package penetration. This same cutting member may also be used to make the initial incision in the chest wall of the patient. The member that re-protects the cutting edge may be a blunt nose that is suitable for bluntly dissecting the tissue between the ribs. In another embodiment of the invention, the blunt nose is configured to form a wedge so that it is able, itself, to force a fenestration in the package or package seal, thus obviating the cutting edge. 
     The chest tube package may be configured with a region that allows for manipulation of the contents so that the chest tube may be advanced out of the package by manual application of force. The region permitting manipulation is an elastic area that is deformable relative to the rest of the package or it is a movable region with a sliding seal between itself and the rest of the package. Either method maintains sterility within the package during moving of the contents. The inner package containing the chest tube may also comprise a region that is specially designed to facilitate penetration by the chest tube. This penetration region is a weakened part of the heat seal or a specially designed port that opens only to permit the chest tube to penetrate the inner package. 
     To facilitate placement of the chest tube, a specialized cutter is configured to perform the initial incision into the chest wall without penetrating below the level of the ribs. This specialized cutter comprises safety features to prevent premature deployment and to prevent cutting too deeply into the chest. This cutter is actuated by manual, electrical or hydraulic/pneumatic force. It may be configured to be a positive displacement cutter or it may be a punch that is loaded and fired or activated under pre-determined force. 
     The chest tube comprises a short insertion portion (the distal segment intended and adapted for insertion into the body of the patient) and a stop to prevent it from being inserted too far into the patient. The short insertion portion has a blunt distal end and is capable of being inserted into a fenestration or incision in the chest wall that was created by either a scalpel and blunt dissection as would be performed by a gloved finger, a Kelly clamp, or a specialized trocar and obturator. The short chest tube is inserted through the incision into the chest cavity. The short chest tube projects through the skin, fat, fascia, between the ribs, and finally through the pleural lining. The tip of the chest tube is soft or blunt or both, and contains no edges or roughness that might erode underlying tissues. The short chest tube is terminated on its proximal segment (proximal to the stop) with a manually openable and closeable valve or it is terminated with a one-way valve that permits only removal of fluids and air from the chest cavity. The short chest tube comprises a flange that prevents excessive penetration into the chest cavity. The flange is designed to stop at the level of the skin surface, or, in another embodiment, the flange is smaller and is inserted into the incision but does not penetrate below the level of the top of the ribs. 
     In yet another embodiment, should lateral penetration of the chest tube be desirable, the short chest tube comprises a trocar and obturator that bluntly penetrates the incision to a pre-determined depth such that it is depth-limited. The trocar further comprises a right angle turn at its distal end that serves to deflect a secondary longer chest tube that is placed through the trocar and which extends laterally in the pleural space to the desired location. The trocar and secondary chest tube comprise a seal system to prevent gas passage between the two components. The trocar further comprises an angular orientation marker that provides an indication to the operator of the direction where the secondary chest tube will be deflected. The orientation markers may be aligned by the practitioner to point to the head or the feet (or other anatomical landmark) so that the deflection is always in a pre-determined direction. 
     The short chest tube may be installed on a patient by unskilled or relatively unskilled medical personnel to treat a trauma pneumothorax in the field. It cannot be placed unsafely and thus paramedics or Emergency Medical Technicians (EMTS) may install the chest tube into patients while they are in the field or the emergency department. The short chest tube is preferably coupled with a specialized blunt or automatic tissue dissector that safely dissects an incision through the ribs. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  illustrates a side view of a chest tube. 
         FIG. 1B  illustrates a lateral cross-section of the central area of the chest tube comprising a generally circular cross-sectional profile. 
         FIG. 1C  illustrates a lateral cross-section of the central area of the chest tube comprising a generally elliptical cross-sectional profile. 
         FIG. 2A  illustrates a side view of the distal tip of the chest tube with a blunt trocar or obturator in the advanced configuration so that the sharp cutter edge of the trocar is protected. 
         FIG. 2B  illustrates a side view of the tip of the chest tube with the blunt trocar or obturator in the retracted configuration so that the sharp edge of the cutter is exposed. 
         FIG. 2C  illustrates a side view of the tip of the chest tube with the blunt trocar or obturator and the cutting blade retracted and removed back through the proximal end of the chest tube. 
         FIG. 3A  illustrates a double aseptic package around the chest tube. 
         FIG. 3B  illustrates the aseptic package with the outer layer removed. 
         FIG. 3C  illustrates the aseptic package with the chest tube advanced out through the inner layer of the package. 
         FIG. 4  illustrates the chest tube advanced into a wound in the thoracic wall of a patient or other animal. 
         FIG. 5A  illustrates a top view of a protective wound disc. 
         FIG. 5B  illustrates a top view of the protective wound disc with its straps wrapped around and adherent to the chest tube. 
         FIG. 6A  illustrates a side view of a chest wall punch, with a retracted blade. 
         FIG. 6B  illustrates a side view of a chest wall punch with the blade advanced. 
         FIG. 6C  illustrates a bottom view of a chest wall punch with the blade advanced. 
         FIG. 7  illustrates a side view of a chest tube, comprising a blunt trocar suitable for penetrating the package and bluntly dissecting into the chest of the patient. 
         FIG. 8A  illustrates a top view of a chest tube in a package comprising an integral protective wound disc and tie down straps. 
         FIG. 8B  illustrates a top view of a chest tube in a package comprising an integral protective wound disc and tie down straps along with an integral pleural drainage system. 
         FIG. 9A  illustrates a side view of an expandable sheath and blunt obturator. 
         FIG. 9B  illustrates a bottom view of the expandable sheath and blunt obturator. 
         FIG. 9C  illustrates a side view of the expandable sheath with the blunt obturator removed and a tapered expanding obturator just being inserted. 
         FIG. 9D  illustrates a side view of the expandable sheath with the tapered expanding obturator fully inserted so that the collet-like split sheath sides are fully expanded. 
         FIG. 9E  illustrates a bottom view of the expandable sheath with the tapered expanding obturator fully inserted. 
         FIG. 10A  illustrates a side view of a short chest tube, shown placed through a cross-sectional view of the outer chest wall. 
         FIG. 10B  illustrates a side view of a short deflecting trocar and chest tube placed into a thorax or chest wall of a patient. 
         FIG. 10C  illustrates a short chest tube with a limit stop. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       FIG. 1A  illustrates a side view of a chest tube  10  of the present invention. The chest tube  10  comprises a length of cannula tubing  12 , an optional integral valve  13 , a plurality of drainage ports  14 , an optional region of gripping surface  15  on the cannula tubing  12 , a drainage lumen  16 , a drainage connector  18 , a cutter  20 , a cutter handle  22 , an obturator  24 , an obturator handle  26  a cutter control mechanism  28 , an obturator control rod  30  (see FIGS.  1 B and  1 C), and a malleable shaft  32 . The cannula tubing  12  is an axially elongate hollow tube affixed at the proximal end to a drainage connector  18 . The central or through lumen of the drainage connector  18  is in communication with the lumen  16  of the chest tube  10 . The drainage ports  14  are penetrations communicating from the outside of the cannula tubing  12  and are in communication with the inner lumen  16 . The cutter  20  is affixed to the distal end of the cutter control mechanism  28 . The cutter control mechanism  28  is slideably affixed within the central or drainage lumen  16  of the cannula tubing  12 . The cutter handle  22  is affixed to the proximal end of the cutter control mechanism. The obturator  24  is affixed to the distal end of the obturator control rod  30 , which is slideably mounted within the drainage lumen  16  of the cannula tubing  12 . The obturator handle  26  is affixed to the proximal end of the obturator control rod  30 . The malleable shaft  32  is affixed to or integral to the cannula tubing  12  and runs along at least a portion of the length of the cannula tubing  12 . The obturator control rod  30  and the cutter control mechanism  28  both traverse the cannula tubing  12  from approximately its proximal end to approximately its distal end. The valve  13  is optional and is optionally configured integrally to the cannula tubing  12  or removably affixed to the drainage connector  18 . The gripping surface  15  is integral to the cannula tubing  12  or it is optionally a separate structure that is movably able to grip the cannula tubing  12 . 
     Further referring to  FIG. 1A , the chest tube  10  is designed to be placed within a patient&#39;s chest and into the patient&#39;s chest through an incision in the patient&#39;s chest to provide for drainage. Using additional components such as a stopcock or one-way valve  13 , the chest tube prevents backflow of air or contaminants back into the chest. Such backflow of air or contaminants could lead to a pneumothorax or infection. 
     The valve  13  comprises a closeable central orifice that is also openable permitting the obturator control rod  30 , the cutter control mechanism  28 , the cutter  20  and the obturator  24  to pass therethrough. The valve  13  is either a one-way valve permitting flow only from the distal tip of the chest tube  10  and not retrograde back toward the distal tip of the chest tube  10  (a duckbill valve, for example) or a stopcock type valve (a ball valve). The valve  13  may be integral to the chest tube  10  or a separate component added proximal to the drainage connector  18 . 
     The gripping surface  15  may be a region of roughness on the surface of the cannula tubing  12 . This roughness may be created by a series of protrusions or depressions in the surface of the cannula tubing  12 , or any other texturing or knurling. The gripping surface  15  may also be a separate structure that is slidably, concentrically affixed to the cannula tubing. When the gripping surface  15  is withdrawn proximally, it slides relative to the cannula tubing  12 . When the gripping surface  15  is advanced distally, it grips the cannula tubing  12  in the same manner as a jamb cleat and advances the cannula tubing  12  distally. 
     The materials used in the manufacture of the cannula tubing  12  of the chest tube  10  include but are not limited to polyvinyl chloride, PEBAX, polyurethane, polyester, polyethylene, PEEK, polypropylene, polytetrafluoroethylene, polyetheretherketone, fluorinated ethylene propylene, polytetrafluoroethylene-perfluoromethylvinylether and silicone rubber. In order to minimize the risk of kinking, the wall of the cannula tubing  12  may be extruded with integral spiral or braided reinforcements manufactured from materials such as but not limited to stainless steel wire, polyimide strands and the like. The cannula tubing  12  may be manufactured from materials with variable durometer or hardness. For example, the proximal end of the cannula tubing may be of harder durometer or thicker wall construction to make that area stiffer than the distal end, thus enhancing pushability and column strength of the chest tube  10 . 
     The obturator control rod  30  and the cutter control mechanism  28  possess column strength and are inelastic in tension. The obturator control rod  30  and the cutter control mechanism  28  are, however flexible to at least some degree and allow bending of the chest tube  10  to minimize the risk of perforating internal organs on the patient while the chest tube  10  is being inserted. The obturator control rod  30  and the cutter control mechanism  28  are fabricated from materials such as, but not limited to, stainless steel, nitinol, Elgiloy and the like. The structures of the obturator control rod  30  and the cutter control mechanism  28  are a solid or tubular axially elongate metal or, preferably, a coil or double helix or a braided reinforcement with a polymer coating or co-extrusion. Such polymer coatings include, but are not limited to, Pebax, PVC, PEEK, PTFE, PET, PETG, polyethylene, polypropylene and the like. 
     The interior walls of the tube  12 , which form the exterior of the drainage lumen  16  and the distal ports are optionally coated with anti-thrombogenic materials to minimize the risk of thrombus. The anti-thrombogenic materials include but are not limited to heparin. The anti-thrombogenic materials are mechanically, covalently or ionically bonded to the material of the tube  12 . The valve  13  and the inner lumen of the drainage connector  18  may also be coated with similar anti-thrombogenic agents. The exterior of the tube  12  as well as the interior surfaces of the chest tube  10  are optionally coated with antibiotics to minimize the risk of infection. This is especially important in contaminated environments. Such antibiotics include but are not limited to erythromycin, amoxicillin, sulfa drugs and the like. 
     The diameter of the cannula tubing  12  ranges from 1 mm to 30 mm and preferably between 2 mm and 15 mm. The length of the cannula tubing  12  ranges between 10 cm and 200 cm and most preferably ranges between 30 cm and 100 cm. 
     The malleable shaft  32  is preferably a length of stainless steel or other metal that is embedded within the wall of the cannula tubing  12 . This malleable shaft may or may not be removable from the chest tube  10 . The malleable shaft  32  extends along at least a portion of the cannula tubing  12  but preferably extends along the full length of the cannula tubing  12 . The malleable shaft  32  is sized so that it may be bent by manual force but resists bending by resilient or elastic forces imposed thereon by the cannula tubing  12 . 
     The drainage connector  18  is preferably fabricated from materials such as but not limited to polycarbonate, polyvinyl chloride, polyethylene, polypropylene and the like. The drainage connector  18  is preferably insert molded or affixed using adhesives to the cannula tubing  12 . The drainage connector  18  preferably comprises a single through lumen. The drainage connector  18  may, however, be “Y” shaped or trident shaped and have multiple connections. Such connections typically use hose barb type fittings but may also have Luer type fittings or other bayonet or threaded connections for interface with other equipment. The drainage connector  18  is sized so that the cutter control mechanism  28  and the obturator control rod  30  may be slideably passed therethrough. The drainage connector  18 , preferably is sized so that the cutter  20  and obturator  24  may be completely removed from the chest tube  10 . 
     The cutter  20  is preferably a circular cutter with its edge beveled to the outside. A circular cutter is also known as a trephine. The plane of the front edge of the circular cutter  20  is preferably not orthogonal to the axis of the tube  12  of the chest tube  10 . The plane of the front edge of the circular cutter  20  is, preferably, disposed at an angle between 5 degrees and 60 degrees from the plane that is orthogonal to the axis of the chest tube  10 . 
       FIG. 1B  illustrates a lateral cross-section of the central area of the chest tube  10  with the cannula tubing  12  cross-section showing the malleable shaft  32  as an integral part of the tubing. The drainage lumen  16  of cannula tubing  12  has the cutter control mechanism  28  and obturator control rod  30  running co-axially throughout the length of said lumen  16 . The cross-sectional outer profile of the cannula tubing  12  is generally circular. 
       FIG. 1C  illustrates a lateral cross-section of the central area of another embodiment of the chest tube  10  with the cannula tubing  12  cross-section showing the malleable shaft  32  as an integral part of the tubing. The drainage lumen  16  of the cannula tubing  12  further comprises the cutter control mechanism  28  and the obturator control rod  30  running coaxially throughout the length of said lumen  16 . The outer profile of the cannula tubing  12  is generally elliptical. An elliptical or rounded rectangular cross-sectional configuration enhances placement of the chest-tube through the intercostal space. By aligning the major axis of the ellipse with the direction of the rib disposition and the minor axis transverse to the direction of the ribs, a chest tube of larger drainage capacity than would normally be allowed by the rib spacing may be inserted between the ribs. Clamps and other devices can be used to insert a large round chest tube that would not normally fit between the ribs except by compressing, or pre-flattening, the tubing cross-section prior to insertion. This compression technique is tedious, wastes time, requires sterile equipment and technique, and increases the chance of contamination to the patient. 
       FIG. 2A  illustrates a side view of the distal end of the cannula tubing  12  comprising the cutter  20  and obturator  24 , further comprising the plurality of drainage ports  14 . The cutter  20  and obturator  24  are in the extended or protected position. 
     Referring to  FIGS. 2A and 1A , the cutter  20  is blunted or protected by the extended obturator  24  so that the sharp edge or sharp tip of the cutter  20  cannot inadvertently cut through the sterile packaging of the chest tube  10 . Such blunting or protection of the cutter  20  by the obturator or blunt tip  24  is selective or controllable. The cutter control mechanism and obturator control rod thus provide means for longitudinally translating the cutter relative to the obturator, so that it may be selectively extended to put the cutting edge distal of the obturator. The means for longitudinally translating the cutter may also be implemented such that the obturator is longitudinally fixed relative to the cannula tubing, in addition to the longitudinally slidable obturator illustrated in the figures. 
       FIG. 2B  illustrates a side view of the distal end of the cannula tubing  12  comprising the cutter  20  and obturator  24 , further comprising the plurality of drainage ports  14 . The cutter  20  is in the extended position while the obturator  24  slightly retracted. 
     Referring to  FIG. 2B , the obturator  22  is slightly retracted to expose the sharp edge of the cutter  20 . The sharp edge of the cutter  20  is now useable to punch through the packaging of the chest tube to facilitate using the tube in emergency conditions or contaminated environments. 
       FIG. 2C  illustrates a side view of the distal end of the cannula tubing  12  comprising the plurality of drainage ports  14 . Referring to  FIGS. 1A and 2C , the cutter  20  and obturator  24  are not visible in this view, as they have been removed from the cannula tubing  12  to open the drainage lumen  16  in order to perform the designed function of the chest tube  10 . 
       FIG. 3A  illustrates the packaging  40  of the present invention. The packaging  40  contains the chest tube  10 , and comprises an outer package  42  and an inner package  44 . The outer package  42  and inner package  44  are sterile barriers for the chest tube  10 . The inner package  44  and the outer package  42  are, preferably, polyethylene pouches that are closed using heat seals. The heat seals are typically from ⅛ inch to ½ inch wide around the perimeter of the pouches. The pouches may have regions fabricated from sterile barrier such as Tyvek that is suitable for use with ethylene oxide (ETO) sterilization and allows said ETO to pass into the pouch but prevents contamination from entering the pouch. The weakened area of the seal can be an area where the seal is less wide (⅛ to {fraction (1/16)} inch) than the rest of the seal. 
     In another embodiment, the outer package  42  is a tray fabricated from materials such as but not limited to polystyrene, polyvinyl chloride, PETG and the like. The trays are typically thermoformed and are covered with a lid fabricated from Tyvek, PETG, polyethylene or the like. The lid is preferably heat sealed to a flange at the open end of the tray. A tray is advantageous over a pouch in that it offers protection against crushing that is not provided by the pouch. The tray, however, is larger, heavier, and more difficult to store and dispose. 
     The double sterile barrier is intended to give the practitioner the option of not using the device after initial assessment of the patient and also for cleanliness and sterility purposes in the field. 
       FIG. 3B  illustrates the packaging  40  with the outer package  42  removed. The inner package  44 , further comprising a gripping region  48 , is still sealed and protects the chest tube  10  from contamination. The gripping region  48  provides an area on the package where the operator may more easily grab the chest tube  10  without slipping. This gripping region  48  is a high friction region relative to the rest of the package. The gripping region  48  is, in a further embodiment, elastomeric in structure and allows the operator to advance the chest tube  10  while the flexible or inflexible, but inelastic, inner package  44  remains relatively undistorted and stable. Suitable materials for fabricating the gripping region  48  include, but are not limited to, polyurethane, silicone rubber, thermoplastic elastomers such as C-Flex, and latex rubber. 
     In yet another embodiment, the gripping region  48  is movably attached to the inner package  44  by means of a sliding or moving seal. This sliding or moving seal is a gasket between the gripping region  48  and the inner package  44  that prohibits passage of contaminants into the inner package  44  but still permits translation or movement of the gripping region  48  relative to the inner package  44 . In one exemplary embodiment, the gripping region  48  includes a plunger that impinges on the friction surface  15  on the chest tube  10 . The operator depresses the plunger or gripping region  48  and the chest tube  10  is forced against and through the inner package  44  seal at seal penetration point  46 . 
       FIG. 3C  illustrates the packaging  40  of the chest tube  10  in the inner package  44 , further comprising the gripping region  48 , with the obturator handle  26  in the partially retracted position. The chest tube  10  in this configuration will allow inner package seal penetration  46  to occur as a result of advancement of the chest tube  10  with the cutter  20  exposed, thus penetrating the inner package  44  seal. The obturator  24  is not visible in this view as it is retracted into the cutter  20  and cannula tubing  12 . This allows for cutter  20  penetration through the inner package  44  at the seal penetration point  46  to maintain sterility until advancement and deployment into the patient. 
     In another embodiment of the invention, the inner package  44  seal is weakened at a specific area where the chest tube is intended to penetrate the seal. This weakened area is, preferably, visibly marked with indicia adequate to inform the practitioner of the location of the weakened area (and, thus, the preferred point of exit) to ensure that the chest tube penetrates the seal at the weakened area of the inner package  44 . In yet another embodiment, an openable window is provided in the inner package  44  where the chest tube is to be advanced out of said inner package  44 . This openable window is, for example, a normally closed elastomeric valve (a duckbill or slit membrane) that is pried open by the chest tube obturator or its cutter. An optional thin seal layer is used to maintain sterility over the openable window, prior to opening. 
       FIG. 4  illustrates the method of installing the device  50  into a patient. The chest tube  10  is contained in a sterile inner package  44  until ready for deployment into patient  52  through an incision site  54 . The access site is first prepared by swabbing or rinsing the area with betadine or other disinfectant, preferably using standard hospital or emergency procedures. The adhesive patch described below or other flexible structure further comprising a disinfectant is applied to the region of the incision. An incision is made in the chest wall using a sterile scalpel, punch or other device. A finger or, alternatively, other blunt device is next advanced through the incision to bluntly dissect through the final layers of chest wall into the chest cavity. The blunt device for dissection may optionally be comprised at the distal tip of the chest tube itself. To deploy the chest tube from its protective package, the user first opens and removes the outer sterile or aseptic packaging layer, maintaining the inner package substantially intact, so that the chest tube can be placed without the need for sterile gloves to be worn by the user. Next, the user grasps the chest tube and the blunt trocar control knob through the inner layer of flexible packaging. The blunt trocar is manually retracted within the cannula exposing the sharpened distal tip of the cannula. The cannula is punched through the inner layer of package by way of the sharp tip and the blunt trocar is now replaced to its protective position. The chest tube is now advanced into the prepared incision in the chest cavity. During deployment, the inner package is left intact over the chest tube, while only the distal end of the tube extends out of the package, ensuring sterility of the chest tube to the maximum extent possible. 
       FIG. 5A  illustrates an aseptic hold-down patch  60  to be used with the chest tube. The aseptic hold down patch  60  comprises a penetration region  62 , a main adhesive region  64 , a hold down plate  66 , a plurality of hold down straps  68 , an adhesive region  70  on each strap, a plurality of pull tabs  72 , and a plurality of partially completed slits  74  within the penetration region  62 . As illustrated, the patch is a disc, but it may be provided in any suitable shape. 
     Referring to  FIG. 5A , the main adhesive disc  64  is permanently affixed to the hold-down disc  66  with adhesive or other fasteners. The hold down-straps  68  are affixed to or integral to the hold-down disc  66 . The adhesive region  70  is on the hold-down strap  68  and the pull-tab  72  is at the end of the hold-down strap  68 . The penetration region  62  is at the center of both the main adhesive disc  64  and the hold down disc  66 . The penetration region  62  comprises slits or score lines  74  that pass partially, but not completely, through from the outside. The slits  74  may also advantageously fully penetrate the main adhesive disc  64  and the hold down disc  66 . The central area around the penetration region  62  is preferably transparent or clear, to permit viewing of the incision site while the hold down disc  66  and main adhesive disc  64  are being advanced against the patient. The hold down disc  66  and the backbone structure of the main adhesive disc  64  are fabricated from materials including, but not limited to, cardboard, polystyrene, polyvinyl chloride, polyester, polyimide, polyamide, polyethylene, polypropylene, and the like, and they may be integrally formed. While the hold down disc  66  and the main adhesive disc  64  should be semi-rigid or have reduced flexibility, the hold down straps  68  are preferably of greater flexibility. The flexibility can be achieved by weaving or knitting structures of the polymers such as polyester cloth and the like. 
     The adhesive region  70  is designed to be fastened to the chest tube to hold the chest tube from being dislodged from the patient. The adhesive region  70  may alternatively be fabricated using Velcro or other fastener systems that mate with corresponding systems attached to the chest tube  10 . If adhesives are used in the adhesive region  70 , a paper or plastic cover strip, removable before use, is desirable to protect the adhesive. 
     The main adhesive disc  64  is coated, on the patient side, with a strong skin adhesive. Such adhesives include cyanoacrylates, but preferably include aggressive adhesives that may be removed or un-adhered such as those adhesives that are used on the pads of electrocardiogram (EKG) electrodes. The adhesive may optionally comprise antigenic, antibiotic or anti-microbial agents such as, but not limited to, silver azide, silver chloride and the like. The adhesive region is, preferably, covered with a plastic or paper cover that is removed by the practitioner, prior to adhering the disc to the patient. Prior to adhesion of the hold down disc  60  to the patient, the practitioner preferably scrubs the area with betadine or other antimicrobial agent using standard aseptic technique. 
       FIG. 5B  shows the hold-down disc  60  adhered to the patient  50 . The hold down straps  68  are wrapped around and adhered to the chest tube  10 , holding the chest tube  10  in place. The cutter handle  22  and obturator handle  26  are not visible in  FIG. 5B  because they have been removed from the chest tube  10 . 
       FIG. 6A  illustrates an incision apparatus  100 , with its cutter retracted. The incision apparatus  100  comprises a cutting blade  102 , a shaft  104 , a chest plate  106 , a bearing  108 , a housing  110 , a spring  112 , a handle  114 , a travel stop  116 , a locking mechanism  118 , and a lock extension  120 . 
     Referring to  FIG. 6A , the cutting blade  102  is permanently affixed to the distal end of the shaft  104  while the handle  114  is permanently affixed to the proximal end of the shaft  104 . The shaft  104  slideably moves through bearing  108  that is permanently affixed to the housing  110 , which is further affixed to the chest plate  106 . The spring  112  biases the shaft  104  so that the cutting blade  102  is retracted within the housing  110 . The travel stop  116  is affixed to the housing  110  and limits travel of the handle  114 . The locking mechanism  118  is affixed to either the chest plate  106  or the housing  110 . The locking mechanism is affixed to the lock extension  120 . The lock extension  120  selectably engages the cutter  102  to prevent inadvertent advancement of said cutter  102  until desired. 
     The cutting blade  102  is preferably fabricated from stainless steel and is configured to form a cross or X. The cutting blade  102  may also be a single blade or other configuration. The cutting blade  102  may be pointed or rounded in side view. 
     The spring  112  is preferably a concentric coil spring fabricated from stainless steel, Elgiloy, nitinol or other suitable spring material. The spring  112  can also be a leaf spring or have a non-concentric configuration. 
     The chest plate  106 , the housing  110 , the handle  114 , the locking mechanism  118 , the lock extension  120 , and the travel stop  116  are fabricated from polymeric materials including as but not limited to PVC, polycarbonate, acrylic, Delrin, polypropylene, PEEK or other suitable rigid material. The chest plate  106  is preferably transparent and may be provided with an adhesive on the skin contacting surface  107 . 
     Referring to  FIG. 6A , the chest plate  106  is placed against the chest of the patient so that the center of the chest plate  106  is at the desired incision point. The chest plate  106  is held against the chest of the patient and the locking mechanism  118  is disengaged. Manual force is applied to the handle  114 , which advances the cutter  102  until such point as the handle  114  hits the travel stop  116 . Release of manual pressure from the handle  114  causes the spring  112  to retract the blade  102  back within the housing. The incision apparatus is designed to cut through only the skin, fascia, and fat of the patient and limit deeper advancement of the blade. The travel stop  116  prevents the blade  112  from penetrating lower than the level of the ribs, so as to avoid damage to underlying organs. 
       FIG. 6B  illustrates a side view of an incision apparatus  100  with its cutter advanced. The incision apparatus  100  comprises a cutting blade  102 , a shaft  104 , a chest plate  106 , a bearing  108 , a housing  110 , a spring  112 , a handle  114 , a travel stop  116 , a locking mechanism  118 , and a lock extension  120 . The locking mechanism  118  has been withdrawn permitting the cutting blade  102  to be forced beyond the face of the chest plate  106  and into the patient. The handle  114  is now impinging on the travel stop  116  to prevent the cutting blade  102  from being advanced too far beyond the chest plate  106  and thus injure the patient. The spring  112  is compressed to provide biasing of the cutting blade  102  away from the patient after the force on the handle  114  is removed. 
       FIG. 6C  illustrates a bottom view of an incision apparatus  100 . The cutting blade  102  is clearly shown with an “X” configuration in this embodiment. The shaft  104  and the bearing  108  are visible in this view. 
       FIG. 7  illustrates another embodiment of the chest tube  10 . The chest tube  10  comprises a length of tubing  12 , an optional valve  13 , a plurality of distal openings or drainage ports  14 , an optional gripping or friction surface  15 , a central lumen  16 , a drainage connector  18 , an obturator  24 , an obturator handle  26 , and an obturator control rod  30 . The length of tubing  12  comprises a wall and a central lumen  16 . The openings  14  are holes extending through the tubing wall from the exterior to the central lumen  16 . The optional valve is affixed integral to or separate from the tubing  12 . The friction surface  15  is integral to the tubing  12  but may be a separate structure slidably disposed over the tubing  12 . The drainage connector  18  is affixed to the proximal end of the tubing  12 . The obturator  24  is slidably disposed within the central lumen  16  of the tubing  12 . The obturator  24  is affixed to the distal end of the obturator control rod  30 . The obturator handle  26  is affixed to the proximal end of the obturator control rod  30  and extends outside the drainage connector  18 . 
     The obturator  24  could also be termed a nose cone, blunt trocar or other designation. The obturator  24  is wedge shaped but could alternatively be symmetrical in configuration. The obturator  24  is not sharp enough to cut through skin under pressures up to 20 pounds. The obturator  24  is, however, able to optionally bluntly dissect muscle and pleural tissue under forces of approximating 20 pounds. The obturator  24  is removed from the chest tube  10  by grasping the obturator handle  26  and withdrawing said obturator handle  26 , which removes the obturator  24  by withdrawing the attached obturator control rod  30 . The obturator control rod  30  possesses column strength and resistance to elongation under tension but is flexible to at least some degree. This flexibility permits the obturator control rod  30  and the chest tube  10  to bend during insertion into the patient, thus minimizing the risk of internal organ perforation. The obturator control rod  30  optionally possesses variable flexibility. It is preferred that the obturator control rod  30  is more flexible toward the distal end and less flexible toward the proximal end. Referring to  FIGS. 1B ,  1 C and  7 , this embodiment of the chest tube  10  may also comprise a malleable shaft  32 . 
       FIG. 8A  illustrates a packaged chest tube system  150  comprising an axially elongate cannula tube  152  with a central lumen (not shown), a plurality of distal openings  154 , an optional one-way valve  156 , an optional shutoff valve  158 , a connector  160 , an obturator further comprising a shaft  162  and a handle  164 , a trocar further comprising an axially elongate cylindrical shaft  166 , a beveled tip  168 , and a limit stop  170 , an inner pouch  172  further comprising a plurality of chevron opening regions  176 , a hold down disc  178  further comprising a protective cover sheet (not shown), a central slit region  180 , a substrate with a clear window area  182  a plurality of hold down ties  184  each further comprising a cannula grip region  186 , and a skin adherence region (not shown), and an outer pouch  188  further comprising a plurality of chevron opening areas  190 , and labeling (not shown). 
     Referring to  FIG. 8A , the cannula tube  152  is an axially elongate tube with a central through lumen having a proximal and a distal end. The distal end of the cannula tube  152  comprises a plurality of perforations, penetrations, or holes  154  that communicate between the exterior of the cannula  152  and the central lumen. The proximal end of the cannula tube  152  is permanently or removably affixed to the one-way valve  156  and further removably affixed, preferably in series, to the shutoff valve  158  as well as the connector  160 . The shaft  162  of the obturator is removably, and slidably placed through the central lumen of the cannula tube  152 . The obturator handle  164  is permanently affixed to the shaft  162  and projects out the proximal end of the cannula tube  152  and any attachments including the connector  160 . The axially elongate shaft  166  of the trocar is concentrically, slidably, and movably placed over the cannula tube  152 . The trocar shaft  166  is sharpened and preferably beveled on its distal end  168 . The proximal end of the trocar shaft  166  is permanently affixed to the limit stop  170 , which further comprises a central through lumen and slidably moves over the cannula tube  152 . 
     Further referring to  FIG. 8A , the outer pouch  188  is preferably comprised of an upper layer and a lower layer not shown. The upper layer and the lower layer are preferably heat sealed together so as to form a complete barrier against microbial contaminants. The band where the upper layer is sealed to the lower layer is called the heat seal  214 . The outer pouch  188  preferably comprises one or more openable areas, or chevrons  190 , that are comprised by heat seals that are disposed diagonally across the corners of the outer pouch  188  to permit a user to grab the upper layer separately from the lower layer and tear the two layers apart at the chevron  190 . The outer pouch  188  further preferably comprises a label, which is either integral or adhered to the outer pouch  188 . The inner pouch  172  is fabricated using similar techniques as the outer pouch  188 . Preferably the inner pouch  172  comprises an upper and a lower layer that are heat sealed together with opening chevrons  176  and heat seals  212 . The inner pouch  172  further comprises a hold down disc  178  that is permanently affixed, removable, or integral to the distal end of the inner pouch  172 . The hold down disc  178  is fabricated from a substrate  182  that forms the main body of the hold down disc  178 . The substrate  182  is coated on the distal most side with an adhesive that is skin compatible and preferably adheres to wet skin. The substrate  182  further comprises a window area, which is a clear or transparent region permitting visibility through the hold-down disc at least in its central region. The substrate  182  is partially, or completely perforated at its central region in, for example, a cross or “X” shape, to permit easy penetration of the hold-down disc by the distal tip of the cannula  152 . The hold-down disc  178  is preferably folded flat so as to be insertable into the outer pouch  188  with a minimum profile. The hold-down disc  178  further is permanently affixed to one or more tie down straps  184  that further are coated with adhesive near the ends to form adhesive regions  186 . The tie-down straps  184  are disposed within the interior of the inner pouch  172 . They may be separate or pre-attached to the cannula  152 . If separate, the adhesive regions  186  of the tie down straps  184  are covered by a protective peel-away layer (not shown). 
     The hold-down disc  178 , in another embodiment, is a flexible, elastomeric, rigid or semi-rigid piece of polymer, metal, or the like and is configured with a soft, pliable exterior edge. The hold-down disc  178 , in this embodiment, is a suction cup that adheres to the patient&#39;s skin by way of suction. A port, valve, and suction bulb for manual evacuation are optionally beneficial to this embodiment in that they can be used to enhance the vacuum bond created by the basic suction cup design. 
     The hold down disc  178  is, preferably, affixed to or integral to the inner pouch  172  and the proximal side of the hold down disc  178  comprises part of the interior of the inner pouch  172 . Because the inner pouch  178  is flexible, the hold-down disc  178 , which is normally in the plane orthogonal to that of the inner pouch  172  or the cannula  152 , may be turned sideways so that it resides in a generally coplanar disposition relative to the inner pouch  178  and cannula  152  during packaging, shipping, and storage. 
     The trocar comprised by the shaft  166 , the limit stop  170  and the sharpened end  168  is very short. The trocar is intended to be forced into a skin incision made in the patient&#39;s chest. The trocar cannot penetrate very far because the distance between the sharpened end  168  and the distal end of the limit stop  170  is limited. In a preferred embodiment, the limit stop  170  is large in diameter and stops against the outside of the skin. The diameter of the limit stop  170  is between 1 and 20 cm, and preferably between 2 and 10 cm and more preferably between 3 and 6 cm. The length of the shaft  166  is between 1 and 10 cm and preferably between 2 and 5 cm. The length of the shaft  166 , in this embodiment, will need to be tailored to the individual because each person has a different amount of fat so different sizes may be required, for example, large, medium, and small. Thus, the distal segment of the cannula which enters the body may be provided in various predetermined lengths to suit patients of varying physique, and the practitioner may select a suitably short device for use after appraisal of the patient. 
     In another embodiment of the trocar, the limit stop is smaller in diameter and stops against the outside of the ribs. In this latter embodiment, the limit stop  170  is passed inside a skin incision and through fat layers so that it stops at or near the outer region of the ribs. The diameter of the limit stop  170  in the latter embodiment is between 1 and 5 cm and preferably between 1 and 3 cm. The length of the shaft  166  is between 1 and 5 cm and, preferably between 1.5 and 4 cm so that it passes through the ribs and into the pleural space but does not project far into the pleural space. This embodiment avoids much of the issues with regard to amount of body fat on a person and allows for a one-size-fits-all approach, so that the distal segment of the cannula may be provided in a single predetermined length suitable for safe, stop-limited penetration through the rib cage. 
       FIG. 8B  illustrates a packaged chest tube system  200  comprising an axially elongate cannula  152  with a central lumen (not shown), a plurality of distal openings  154 , an optional one-way valve  156 , an optional shutoff valve  158 , a connector  160 , a trocar further comprising an axially elongate cylindrical shaft  166 , a beveled tip  168 , and a limit stop  170 , an inner pouch  202  further comprising an upper layer and a lower layer (not shown), a plurality of heat seals  212 , a drainage volume  204 , a drainage inlet manifold  206 , an optional vacuum port  208 , an optional stopcock  210 , an optional vacuum pump (not shown), a hold down disc  178  further comprising a protective cover sheet (not shown), a central slit region  180 , a plurality of hold down ties  184 , a substrate with a clear window area  182 , and a skin adherence region (not shown), and an outer pouch  188 , further comprising an upper layer and a lower layer (not shown), a plurality of heat seals  214 , a plurality of chevron opening areas  190 , and labeling (not shown). 
     The embodiment of  FIG. 8B  is similar to that of  FIG. 8A , except that the inner pouch  202  comprises the drainage volume  204 , the drainage inlet manifold  206 , the optional vacuum port  208 , the optional stopcock  210 , and the optional vacuum pump. These components are either integral to the inner pouch  202  or are affixed and bonded to the inner pouch  202  using heat, solvents, adhesives, ultrasonic welding, or the like. Referring to  FIG. 8A , the cannula  152  of  FIG. 8B  does not comprise an obturator shaft  162  or handle  164 , although these could be added, if desired. In this embodiment, the extreme distal tip of the cannula  152  is advantageously of increased stiffness, or has decreased flexibility, relative to the rest of the shaft  152 . In this way, by careful location of the distal tip of the cannula  152  relative to the trocar shaft  166  and sharpened end  168 , the cannula  152  serves the function of the blunt obturator. 
     Referring to  FIG. 8B , the drainage volume  204  serves as an integral collection device, much like a pleur-evac. The drainage volume  204  is connected to the connector  160  of the cannula  152  by way of the drainage manifold  206 . The drainage volume may comprise an optional standoff to maintain a finite internal volume for maintenance of a pre-applied or generally applied vacuum. The vacuum pump may be a simple manual bulb or it may be any of the typical manual or electromechanical devices available. 
     Further referring to  FIGS. 8A and 8B , the method allows for placement of a chest cannula  152  in a patient without the need to use gloves since the cannula  152  and any associated apparatus is handled through the protective pouches or bags. The entire system is sterilized. The chest tube  152  and its components, and the inner pouch  202 , both inside and outside, are maintained sterile by the outer pouch  188 . The patient incision site is first swabbed with iodine, betadine, or other disinfectant. An incision is made, with a sharp blade, through the skin and into the fat layers. After removal of the outer pouch  188 , the chest tube or cannula  152  may be manipulated through the inner pouch  202 . The hold down disc  178  is adhered to the skin at the incision site. The trocar and concentrically mounted chest tube  152  are forced through the central slits  180  in the hold-down disc  178  and into the incision. The trocar is forced into the incision until the limit stop  170  hits the hold down disc  178 . The trocar is withdrawn and the chest tube cannula  152  is advanced into the incision. Once placement is acceptable, the tie down straps  186  are wrapped around the cannula shaft  152  and chest drainage management can commence. 
       FIG. 9A  illustrates an expandable trocar  250  comprising a limit stop  252 , a plurality of split sleeves  254 , an obturator stop  256 , an obturator handle  258 , and an obturator shaft  260 . 
     Referring to  FIG. 9A , the plurality of split sleeves  254  are disposed concentrically at their minimum potential diameter. The split sleeves  254  are embedded in or affixed to elastomeric or malleable material that is affixed to a central lumen of the limit stop  252 . The obturator shaft  260  is preferably rounded at its distal end and is affixed to the obturator stop  256 , which is further affixed to the obturator handle  258 . The obturator shaft  260  is movably, removably, and slidably disposed within the central lumen described by the split sleeves  254 . The rounded distal end of the obturator shaft  260  is positioned so that when the obturator stop  256  is against the proximal side of the limit stop  252 , the rounded section fully projects beyond the distal end of the split sleeves  254 . 
     The number of split sleeves  254  is between 2 and 100, and preferably between 4 and 50, and more preferably between 6 and 20. 
     The region between the split sleeves  254  is either open or it is filled in with an elastomeric material such as, but not limited to polyurethane, silicone elastomer, thermoplastic elastomer, latex rubber, polyethylene foam, polyvinyl chloride foam, polyurethane foam, and the like. 
       FIG. 9B  illustrates a bottom view of the expandable trocar shown in  FIG. 9A , further comprising the obturator shaft  260 , the plurality of split sleeves  254 , the limit stop  252 , and the expandable region  262 . 
     Referring to  FIGS. 9A and 9B , the limit stop  252  as well as all components of the obturator are preferably fabricated from metals such as, but not limited to, stainless steel, cobalt nickel alloys, nitinol, or titanium, or polymeric materials such as, but not limited to, polyethylene, polypropylene, polycarbonate, polyester, polyvinyl chloride, ABS, and the like. The elastomeric or malleable material, in which the split sleeves  254  are embedded, is preferably a material such as, but not limited to polyurethane, silicone elastomer, thermoplastic elastomer, latex rubber, polyethylene foam, polyvinyl chloride foam, polyurethane foam, and the like. The split sleeves  254  are fabricated from materials such as, but not limited to, stainless steel, cobalt nickel alloys, nitinol, or titanium, and the like. The elastomeric region in the limit stop  252  embeds the split sleeves  254  and allows them to expand under the force of a tapered obturator or central insertable mass. In another embodiment, the elastomeric region  262  is replaced by cantilevered split sleeves  254  that are embedded into the limit stop  252 . The split sleeves  254  are leaf springs and expand in the presence of a large insertable central mass. 
       FIG. 9C  illustrates the expandable trocar  250  of  FIG. 9A  with the obturator components  260 ,  256 , and  258  removed and a large expanding obturator  270  being inserted. The large expanding obturator  270  further comprises a tapered region  272 , a blunt rounded tip (not shown), a straight shaft  274 , and an expanding obturator handle  276 . The expanding obturator  270  has not been inserted far enough to cause any expansion of the split sleeves  254 . 
       FIG. 9D  illustrates the expandable trocar  250  with the large expanding obturator  270  having been fully inserted therein. The split sleeves  254  have opened up forming a series of fingers that are intended to pry open or expand tissue. The blunt tip  278  of the expanding obturator  270  is visible in this view. It is preferable that the blunt tip  278  not project beyond the distal ends of the split sleeves  254  but a small amount of projection, as shown, is acceptable. 
       FIG. 9E  illustrates a bottom view of the expandable trocar  250  with the large expanding obturator  270  having been fully inserted therein. The elastomeric or malleable region  262  has become much narrower than in the unexpanded state of  FIG. 9B , due to the expansion of the embedded split sleeves  254 . 
     Referring to  FIGS. 9A through 9E , the expandable trocar permits placement of a small diameter trocar through the thoracic wall, a procedure which is fairly commonplace and easy. However, by removal of the small obturator and full insertion of the large expanding obturator  270 , the trocar  250  and the hole in the tissue it supports is expanded greatly and in such a way that a chest tube could be inserted therethrough. In yet another embodiment of the expandable trocar  250 , the obturator shaft  260  is sharpened and capable of cutting through the skin, fat, fascia, and muscle of the patient. The sharp tip on the obturator shaft  260 , in this embodiment would be retracted automatically by standoffs that projected distally of the limit stop  252  and were attached to the obturator stop  256  or obturator handle  258 . Automatic retraction of the sharp tip of the obturator shaft  260  would permit a one-step procedure or method to punch a hole in the thoracic wall and insert the trocar  250  through the ribs to the limit stop  252  without the need of a scalpel or other sharp object to make the initial skin incision. 
       FIG. 10A  illustrates a short chest tube  300  comprising a cannula tube  302 , a plurality of drainage holes  314 , a limit stop  304 , a tube standoff  306 , a one-way valve  308 , a stopcock  310 , and a drainage connector  312 . The short chest tube  300  is shown inserted through an incision through a skin  320 , a fat layer  322 , a layer of fascia  330 , a region of intercostal muscle  324 , between the ribs  326 , through the pleura  328 , and into the pleural space  332 . 
     Referring to  FIG. 10A , the cannula tube  302  is an axially elongate hollow tube with a proximal and a distal end. The proximal end of the cannula tube  302  is affixed to the limit stop  304 , which is affixed to the tube standoff  306 , which is affixed to the one-way valve  308 , which is affixed to the stopcock  310 , which is affixed to the distal end of the drainage connector  312 . A central through lumen is maintained from the distal end of the cannula tube  302  to the proximal end of the drainage connector  312  so that fluid can be drained from the thoracic cavity. The one-way valve  308  prevents backflow into the thoracic cavity but opens to provide a through lumen for drainage. The stopcock  310  provides manual shutoff or opening of the through lumen. The drainage holes  314  communicate between the through lumen and the outside of the cannula tube  302 . The plurality of drainage holes  314  are provided since a single hole, at the distal tip for example, might become occluded with tissue and drainage could not occur. The plurality of holes  314  separated by the material of the cannula tube  302  provides a standoff for the tissue and maximizes the surface area for drainage of the pleural space. 
     Referring to  FIG. 10A , the short chest tube  300  may be forced between the ribs  326  and into the pleural space  332  with reduced risk of damage to internal organs since the distal end of the cannula tube  302  is rounded and blunt. In addition, the length of the cannula tube  302  is short so that it projects just a small amount into the pleural space  332 . The cannula tube  302  is provided, for example in several lengths to accommodate people with different thicknesses of body fat. The diameter of the cannula tube  302  is between 0.25 cm and 4 cm and preferably between 0.5 cm and 2 cm. The limit stop  304  prohibits the short chest tube  300  from being advanced too far into the patient and, thus, minimizes the risk of damage to the underlying organs such as the heart and lungs. The lengths and diameters of the limit stop  304  and the construction materials is the same as that described for the trocar  250  shown in  FIGS. 9A through 9E . 
       FIG. 10B  illustrates a short deflecting trocar and chest tube system  350  where the trocar comprises a trocar tube  352 , a deflecting tip  354 , a limit stop  356 , and a sealing handle  358 . The chest tube comprises a cannula  360 , a plurality of drainage holes  362 , an optional obturator shaft  364  and an optional obturator handle  366 , a one-way valve  368 , a stopcock  370 , and a drainage connector  372 . The short deflecting trocar and chest tube system  350  is shown inserted through an incision through a skin  320 , a fat layer  322 , a layer of fascia  330 , a region of intercostal muscle  324 , between the ribs  326 , through the pleura  328 , and into the pleural space  332 . 
     Referring to  FIG. 10B , the short deflecting trocar and chest tube system  350  permits placement of a short trocar through the ribs and into the pleural space. A chest tube cannula  360  is then inserted therethrough and deflected so that it can route parallel to the plane of the chest wall to a desired location. The obturator shaft  364  and the obturator handle  366  are preferably omitted from the system but may advantageously be added if additional column strength or steerability is desired. 
     The trocar sealing handle  358  is fabricated from rigid polymers such as, but not limited to ABS, PVC, polyethylene, polypropylene, polysulfone, polycarbonate, and the like, and further comprises a central lumen with an elastomeric seal through which the cannula shaft  360  may slidably and movably pass but which seals and prevents the passage of air or liquid around said cannula shaft  360 . The elastomeric seal (not shown) is fabricated from materials such as, but not limited to, silicone elastomer, latex rubber, thermoplastic elastomer, polyurethane, and various closed-cell or open-cell foams. The inner surface of the elastomeric seal is advantageously coated with a lubricant such as silicone oil, or the like, to facilitate movement of the cannula shaft  360  through the sealing handle  358 . 
     Referring to  FIG. 10C , the limit stop  304  is sized and dimensioned to permit advancement through the fat layer  322  overlying the patient&#39;s rib cage, but prevent advancement into the narrow space between the ribs  326 . In this arrangement, the length of the tube  302  distal to the stop is set at a predetermined length corresponding to the average thickness of the ribs, so that the distal tip of the tube extends into the pleural space  332  without significant risk of injuring tissue therein. In all other respects, the chest tube may be similar to the chest tubes of the previous figures. 
     The advantage of the aforementioned devices and methods improves the ease with which a chest tube may be placed, especially by less well-trained personnel such as paramedics and emergency medical technicians. 
     Application of the chest tube system provides improved speed of application of the chest tube, especially in contaminated environments. The application of this chest tube system facilitates damage control procedures wherein the patient can be allowed to stabilize prior to definitive repair of the injuries. The aseptic hold-down disc and the incision apparatus allow for quicker application of the chest tube by paramedics and emergency personnel with less chance of wound contamination, internal damage to the patient or chest tube dislodgement. 
     The present invention may be embodied in other specific forms without departing from its spirit or essential characteristics. For example, the aseptic hold down disk may have more than two straps to restrain the chest tube. The incision apparatus may have a cocking mechanism to retract and then fire the cutter, rather than using positive hand pressure to advance the cutter. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is therefore indicated by the appended claims rather than the foregoing description. All changes that come within the meaning and range of equivalency of the claims are to be embraced within their scope.