I Don't Crash Just to Have Something to Write About

I've talked about blunt chest trauma before, discussing rib and lung injuries, and blunt cardiac injuries. I had been meaning to follow back up on this to talk about how to assess breathing without having to actually count respirations or measure oxygen saturation. I'm finally getting around to that and I'll use a recent personal scenario to help differentiate mild to more severe injuries (image: partially collapsed lung on CT scan).

"I was just riding along..."

There's probably no more prolific lie in the bike industry other than "just riding along." It's abbreviated to J.R.A. and is usually associated with a bike that looks like it was used to recreate Josh Bender's Jaw attempts (a 55ft "drop").

Josh Bender

That being said, for this, I was in fact, just riding along ... on an easy, wide, flat, trail when I suddenly found myself painfully upside down against a tree. I was moving at a *decent* speed, but not one that I would call "fast," and to this day I don't really understand why this happened. There's small root/stump that I must have hit, but nothing I would call "an obstacle," and not one that I would have expected to stop me cold.

Anyway, there I was, on the ground, and I did my assessment:

• I was awake, alert and fully aware of my situation. 
• I did not appear to have injured my head or neck, as it was quite apparent at the time that all of the impact was on the left side of my upper back.
• I was kneeling, and using my hands to hold myself up, and no extremities seemed to be injured.
• But man, I was in pain and I really couldn't breathe.

What does the level of pain & ability to breathe mean?

When I discuss blunt chest trauma in my courses, I talk about a continuum of injuries such as:

• Chest/Rib contusion--bruising
• Cracked Rib(s)--cracked, but not completely broken
• Broken Rib(s)--a fracture and a break are the same thing
• Flail Chest--multiple ribs broken in two places
• Pneumothorax--collapsed lung filled with air
• Hemothorax--collapsed lung filled with blood

Without the availability of x-ray or CT scan, it's impossible to really say what is going on after a fall. Sure, you *might* have a portable ultrasound, but I'm guessing that most of you do not (image: pulmonary contusion on CT scan).

But what can help you figure out where on this spectrum of injuries an injured person stands is the way that he or she is able to breathe and move.

Chest or rib contusions might be *sore,* but really shouldn't be very painful, A person with bruised chest/ribs is probably going to move, breathe, and talk relatively normally. 

Cracked ribs are going to hurt a bit more. Someone with cracked ribs should still be able to breathe, talk, and move normally, but might have some pain with strenuous movement or deep breathing.

Broken rib(s) are going to hurt just at rest, but will really hurt with deep breathing or even minor movements. People with broken ribs usually have pain with reaching to pick up something or twisting. A person with broken rib(s) should be able to breathe adequately while at rest, as long as deep breaths aren't needed. He or she may be taking shallow breaths, but likely won't feel like they're not getting enough air. He or she may also feel a "clicking" with breathing or moving.

A flail chest is going to be awful. The multiple broken ribs will create a "flail segment" that will move in the opposite direction of the rest of the chest/ribs when inhaling or exhaling. This it going to hurt just to exist, and breathing is going to be problematic. This person is really going to be exhibiting signs of distress and will need help to come to them--this would only happen from significant trauma.

So to recap, you can see how the minor injuries will have relatively minor symptoms while the more serious injuries are going to be more obvious.

Lung injuries

The lungs are stuck to the inner side of the ribs by a membrane called the pleura. Significant trauma can disrupt the pleural lining and create a space between the lung and the ribs. That space can fill with air (pneumothorax) or in some cases, blood (hemothorax). Depending on the size of the pneumothorax/hemothorax, a lung can completely collapse leaving a person with just one usable lung and a lot of pain. 

Even when just part of the lung collapses, a person has less lung capacity and will usually have lots of pain and shortness of breath. 

And here's where I found myself. 

On my hands and knees, unable to talk, only able to grunt. 

I was about a mile from a trailhead so I texted my wife and asked her to come get me. She took my "I can't talk," to mean that I was on a call or something, not, "I can't talk."

With the pain I was in, and the difficulty I was having breathing, I figured that I had at least a couple of broken ribs and I was worried about a pneumothorax.

My wife picked me up, threw my bike in the truck, and took me to work, eh, the hospital. I got to walk in my workplace as a patient. 

My colleagues didn't harass me too much, but I was worried when my chest x-ray showed a whole lot of nothing.

"Am I really that big of a wimp?" I thought. I'd never live it down if I came to the emergency department without a real injury...

However, I also mention in my courses (and to many patients), that X-rays are *okay* at looking for broken ribs, but not great. X-rays do miss many broken ribs. In reality, we're looking for lung injury (collapsed lung=pneumothorax or lung contusion) which *usually* shows up on X-ray. 

I had gotten some anti-inflammatory meds and was actually feeling much better. I was moving around and asking my wife "if I had broken ribs, could I do this?"

The doc who was taking care of me had also ordered a trauma CT scan, which we do when we're worried about internal injuries or injuries missed on X-ray.

My friend the CT tech let me know that my images didn't look great, and when the radiologist finally read the images, the total tally was 5 broken ribs (one was just "probable" though), a small pneumothorax and a pulmonary contusion (bruised lung tissue).

Ha, I was vindicated, and I had diagnosed myself correctly in the woods, but I also had to spend the night in the hospital because if the pneumothorax got bigger, I'd need a chest tube, which I did not want.

Fortunately I was out of the hospital the next day, mowed the lawn, and got ready for vacation. I couldn't sleep, and laughing or coughing was "uncomfortable," and our vacation was more tame than we had hoped, but missing work for an injury is one thing, missing a vacation is something else.

The moral or the story is that the degree of pain a person is in and the difficulty he or she has or isn't having will help, at least initially, determine the severity of an injury. 

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