A 22-year-old male presents to the ED after having been shot in the left chest during an attempted carjacking.  The bullet entered into the left chest just medial to the left shoulder.  Initially, the patient was awake and alert with BP 124/64, HR 92 and RR 16.  His chest xray revealed several bullet fragments in the left chest and one fragment in the right chest.  The cardiac silhouette was normal.  His blood pressure subsequently decreased to 82/54.  You perform a FAST exam (his abdominal windows were negative and thoracic windows demonstrated no evidence of a pneumothorax) and note the following:

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