Note: None of the contents of this article are meant to replace the advisement or care of a real medical professional. This information is for use solely in emergency situations where access to professional medical care is going to be delayed. This is not a long term life saving measure, just something to keep someone alive until they can reach professional medical help. The author of this article and the owner of this website will not be held legally responsible for any injuries or death that come as a result of your attempts to utilize this information.
How to Save a Life: Emergency Medical Techniques When Medical Supplies Aren’t Available/How to Diagnose & Treat Flail Chest in the Field
Setting the Scene: So you’re walking along with your buddies, discussing the possible implications of the large hadron collider on our understanding of string theory (or if Megan Fox looked better running in Transformers or Transformers 2). The skies are clear, it’s a beautiful Friday afternoon. You and your buddies are heading to the beach for the weekend to enjoy your three day pass (hey, it’s a fantasy, three day passes can get approved here). Everything is perfect in the world.
Knowing your crowd, you mention that there is a new Rambo movie being produced. Everyone is excited by the news, eager to hypothesize about the shenanigans ‘ol John would be getting himself into this time around. Everything is going great until one of your buddies, who we’ll just call “That Guy”, decides to make an unprecedented statement of idiocy. “Stallone is getting too old.” He begins his tirade of lunacy. You see that he is about to continue speaking. You and your friends try to stop him, but you’re too late. “Rambo needs to retire,” he goes on. You’re screaming for him to stop before it’s too late, but the sound of your voice is lost to a howling wind that seems to have appeared out of nowhere. Then That Guy puts the final nail in his own coffin, “I could take Rambo in a fight.”
His words are the only sounds left hanging in the air, echoing into a vast abyss like thunder into a great canyon. That Guy seems to be the only one oblivious to the changes in the environment. The beautiful Friday afternoon sky has filled with dense thunderclouds. The warm air has turned ice cold; the cold of death. A single tumbleweed rolls over the road in front of you. In the wake of the tumbleweed: John Rambo. The world seems frozen in time. The only movement is that of Rambo’s bandana, with tails trailing in the wind several feet behind him like a scene out of a John Woo movie.
Rambo looks up at That Guy, furious eyes crackling with electricity. Finally realizing his mistake, That Guy attempts to apologize, but he’s too late. Mistakes have been made; comeuppance must be served. And in the land of Rambo there’s only one form of payment: blood. Rambo doesn’t so much move to your friend, so much as he fades from one spot to the next without changing the position of his limbs, like a scene in an anime where (I think) the intent is to show incredible speed. In no time at all he stand in front of That Guy. Without a word, he lifts one size 16 combat boot high into the air, and plants the sole of it right into That Guy’s chest. The power of the blow carries That Guy off of his feet, and straight onto his back. He lays on the cement with Rambo’s now size 18 boot crushing into his ribcage. He feebly pleads with Rambo for forgiveness, mouthing breathless apologies.
Moved by your friend’s newfound sense of humility, Rambo, in an uncharacteristic act of mercy, removes his size 20 combat boot from That Guy’s chest. He looks around to see if he has any more challengers to his throne, but is met only with bowing acquiescence. You know that Rambo has only once before shown this kind of mercy, and it’s not bound to happen again in one day. Then, with a slight nod of his head, Rambo disappears as suddenly as he came. The clouds have cleared from the sky. The birds return to chirping, and the cold of death has left the air. You can’t believe you got off this easy! You turn to your friends to see if anyone thought to get his autograph, when you realize That Guy is still on the ground, gasping for air. He can barely speak, and he’s mouthing that he can’t breathe. You quickly realize that this has the potential to ruin your three day weekend. If he dies, you know you’ll spend the entire weekend up at battalion HQ with the commander asking why you all felt the need to urinate in his breakfast cereal of choice instead of chilling on the beach. You’ve got to act fast.
The Assessment: Diagnosing Flail Chest.
You run up to That guy to see what is the matter. You ask him if he’s okay, but he can barely verbalize a response. Thinking back to your Combat Lifesaver class, you remember that your first concern is any massive hemorrhages, and then you need to check your ABC’s (Airway, Breathing, and Circulation).
You do a quick pat-down of his front and back sides to check for any obvious bleeding (yes, even the groin. You’re probably going to want to know if the damage (I’m coining that) has led to a priapism, indicative of spinal damage, or rectal hemorrhage, indicative of internal bleeding). Miraculously, Rambo has not caused your friend to start hemorrhaging out of every orifice, so you move onto your ABC’s.
You put your head down next to his mouth, to listen and feel for air flow while you look at his chest to ensure proper rise and fall that would signify proper air exchange. But when you’re looking at his chest, you realize that something seems off. Part of the chest wall doesn’t seem to be moving like the rest. Recalling the infamous words of your Drill Sergeant, you remember that when, “One of these things don’t look like the others… you’re all jacked up.” Oh no, That Guy must be jacked up!
You quickly lift his shirt up to expose the area, just as you were taught. When you do, you’re met with a sight that seems like it came straight out of the movie Alien. When he breathes in, and his chest is expanding, you see that a large chunk of his chest wall sinks inward. When he exhales and his chest wall is moving downward, that same portion of his chest now rises. Get back, here comes the Alien!
Not really though, please don’t dial Sigourney Weaver. What you’re seeing is called paradoxical motion of the chest wall, and it’s a bad sign. Here’s a video to show you what it looks like in real life. Just click that part where I said that. The video is on a different page, it’s called a hyperlink. Long story.
Okay, so now that we know what we’re looking for, what exactly are we looking at? To understand that, we need to know what flail chest is. It is usually the result of a crushing injury or blunt force trauma, and it is most definitely a life threatening condition. Flail chest is defined as 3 or more consecutive ribs that are broken in 2 or more places. Read that twice.
What this creates is a floating section of ribs that is completely detached from the ribcage itself. This destroys the rigid integrity of the ribcage which is necessary for proper air exchange. The lungs ability to expand and contract is a direct result of the integrity of the chest wall. To breathe air in, your chest wall expands as your diaphragm contracts. This creates a vacuum that pulls air into the lungs. However, if you have a free floating section of ribcage, when your chest wall expands outward, the vacuum created pulls the free floating section of ribs inward. When your chest wall contracts (exhaling), the positive pressure created pushes the free floating section of ribs outward. This is what creates the paradoxical motion we saw in that lovely video above.
Some other signs and symptoms you may see include:
Dyspnea- painful and/ or difficult breathing
Tachypnea or bradypnea- Abnormally rapid or slow breathing. But wait, how could the same condition cause the complete opposite effects in two different people you ask? Solid question. The answer lies in the position of the broken bone segments, and the location of the free floating bone section. In some patients, the location does not significantly interfere with mechanical respiration. In these cases, the pain caused by the injury may lead the patient to try to hold their breath, leading to slow breathing (bradypnea). In other patients, the injury does significantly interfere with the ability to exchange air, in which case their respiratory reflex will shoot into overdrive. This causes tachypnea (abnormally fast breathing). It is more common in unconscious patients, where the pain of the injury will not cause a conscious suppression of the respiratory reflex, but can be seen in conscious patients as well.
Pain- Ohhhhhh, so much pain. Probably more than they’ve ever experienced, unless the patient is Rambo instead of being a patient because of Rambo. You’re going to have to do some stuff to treat them that will cause more pain, but will lead to them feeling better. They may get angry, they may fight you; but in the long run, when they’re alive enough to do so, they will thank you.
Cyanosis- Blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.
Bruises, grazes, and/or discoloration in the chest area- They will likely have a very large, pronounced bruise over the chest area. Any time this is seen in any patient, you must treat them as if they have open fractures in the ribcage until x-ray imaging proves otherwise. We’ll talk more about this in the treatment section.
Telltale markings from a seat belt
You’ll also want to monitor the patient for shock. The two main ways you’ll determine this in the field without equipment are an altered level of consciousness and/or absence of a radial pulse. Once a patient goes into shock (if not prior), all efforts should focus on getting them to definitive care.
As soon as you recognize what is going on with your patient, call for help! If you’re in the sandbox, radio for Medevac ASAP. This is a priority 1, and you don’t want to have to treat it long term in the field. They need professional medical attention now. If you’re stateside, have a buddy/ bystander/ Kmart shopper dial 911.
Once emergency medical personnel have been notified, it’s time to get to work. With the immense amount of pain the patient is in and the difficulty they are probably experiencing with breathing, it’s tempting to think that these would be your primary areas of concern. You’d be wrong. Don’t worry, it doesn’t make you a failure. You’re still a great person with a wonderful personality.
The most dangerous aspect of flail chest is that there are now razor sharp bone ends directly over their lungs. Those sharp bone segments are moving against the natural movement of the chest, which essentially equates to having knives grating around in your chest cavity every time you breathe. You’re going to want to address that. Don’t press on it unless you’re sure their heart has stopped. If it has, you’re not going to do any additional damage anyway, so you may as well give it a try. If you’re unsure if it’s flail chest, but they’ve got the symptoms that make you suspect it; treat it as flail chest until proven otherwise.
In the hospital, they’re going to be placing the patient on 100% O2 via non-rebreather mask with mechanical ventilation to prevent the ribs from floating freely. You’re in the field, so you probably don’t have that stuff. So we’ve got to work with what you’ve got. If you’ve got you woobie, now is a good time to bust it out. Yes those wonderful inventions can be used as more than a spooning replacement for your girlfriend while deployed. If you don’t have your woobie, stop everything! Where is your woobie? Nothing else matters until you’ve found your woobie. No, I’m just kidding. Use a folded towel, blanket, or pillow; even an unused IV bag can work in a pinch. Use whatever it is you found to splint the area of free floating ribs. This prevents the paradoxical motion of the segment, hence reducing the risk of perforating a lung.
If you are not in immediate danger, and don’t need your hands free for things like patty-cake or using your rifle, continue to splint the area manually. If that’s not an option due to an intense patty-cake tournament or because you’re taking enemy fire, try to have the patient splint the area. You want to avoid having to tape around the chest to keep the splint in place, because doing so further interferes with breathing.
After that, continue to monitor the patient for signs of decreased ability to breathe. If that comes up, readjust the splint. If all else fails, go to providing manual positive pressure ventilation (pucker up, this means mouth to mouth). Check on where that Medevac is; inform them that you know that it’s sandy outside, but you’re still going to need them to fly. Observe the casualty for signs and symptoms of tension pneumothorax and hemothorax (which we’ll have to discuss the treatment of in another article). Monitor the patient’s vital signs and level of consciousness until help arrives.
And then everyone lives happily ever after. Because they’re alive; because you’re a hero. And you get the girl, for sure. Wait, forget the girl. Seriously, did we ever track down that woobie? Ahhh, there it is. I love you woobie.
(picture courtesy of IMDB.com and www.lhsc.on.ca)