A 20-year-old male is brought in by paramedics after suffering two stab wounds to his chest. In the emergency department, the patient is awake but combative. He responds to questions by stating his name but is flailing his arms and shouting to leave him alone. His breath smells of alcohol. On physical examination, his blood pressure is 88/70 mmHg, heart rate is 110/min, and respiratory rate is 20/min. His airway is patent. Breath sounds are absent on the left and clear on the right. He has two stab wounds to the left chest, one just above and one just below the nipple. There is no bubbling of air from the wounds. There is palpable crepitus over the left chest. His neck veins appear to be distended. His trachea is midline. The heart sounds are difficult to hear, but the rate is regular but fast, without murmurs. The abdomen is soft and non-tender. The patient is log-rolled and no other injuries are identified.