Episode 2 of SciFiMedic Explains: How do I write broken ribs with primitive field surgery for a collapsed lung?
Original prompt submitted by @lancedoncrimsonwings.
“Character has broken ribs on one side, then fell from a horse (landing on the injured side and dislocating their shoulder by trying to brace to protect their ribs). Is it likely the fall would worsen the break, and if a rib punctured their lung, how would someone with them first aid that in the wilderness? (Medieval times, generally). They have access to water, a dagger, a form of herbal ish pain relief/sedative made from poppies, and reeds. Survivable or nay?”
Falling from a horse may seem fairly mundane, but many life threatening injuries can happen, especially if the horse steps on you. To end up with a dislocated shoulder, they would most likely land on their outstretched arm.
The instinct to fling out an arm when falling is stronger than the instinct to pull in and brace broken ribs. The shoulder would most likely dislocate anteriorly from this kind of injury.
Here’s a step by step guide on reducing a shoulder via the Hennepin technique:
Lie down. Flat on their back with no pillow.
The person who’s helping them should gently grab the injured arm by the wrist and bend the elbow to 90 degrees. Support the elbow with one hand, hold the wrist with the other. You can also hold their hand.
Gently press the elbow to their side.
Keeping the elbow near their side at all time, gently pull their wrist away from their body, externally rotating their shoulder away. This should go extremely slow, at least 10 minutes to allow muscles to relax.
The shoulder will make an audible “pop” when it slides back into it’s socket. The pain goes away immediately, but is replaced with a dull throb a few hours later. You want to bind the arm to the chest to prevent movement of the joint as it heals.
Now… it sounds like a dislocated shoulder isn’t the worst of their problems. Whoever is helping them may be more concerned about their obviously injured shoulder and focus on treating that first, while completely missing the fact that they’re showing symptoms of a pneumothorax, which is what happens if a rib punctures a lung.
There are two ways you can play this.
Option 1: Closed-Simple Pneumothorax
This can happpen when a broken rib pops a hole in the lung. This can be a tiny little nick, or a larger hole. Because it’s simple, that means that the air that’s coming into the pleural space (the area between the outside of the lungs and the inside of the chest, normall filled with slick fluid) is able to get back into the lungs again. There is a slight pressure build up, and the lung is slightly compressed, but you can have a simple pneumothorax and not notice it for literal months. The treatment is simple, let it heal on its own. There’s not much you can do, even with modern surgical practices. It’s better for everyone to leave it be.
Option 2: Closed-Tension Pneumothorax
Based on the supplies you’ve given me, this is probably what you’re thinking. A tension pneumothorax happens when that air coming into the pleural space isn’t able to get out. With each breath, more air is forced around the lung, collapsing it. The only way to relieve this pressure is to manually release the air by poking a hole in the chest wall. Before you do that however, we have to make sure they actually have a collapsed lung. Here’s the signs & symptoms:
Decreased breath sounds on the bad side
Jugular Vein Distension (photo)
Tracheal deviation away from injured side (photo)
Blue lips and fingernails
While this is not a pneumothorax case, I could correctly diagnose a right-side tension pneumothoarx from this picture and listening to breath sounds.
Alright, you’re sure it’s a pneumothorax? Fantastic. Now it’s time for the fun part. Here’s a step-by-step guide using the supplies (and time period) you’ve given me.
Step 1: Identify the site you’re going to poke a hole. Refer to handy-dandy diagram for reference.
Step 2: Clean as best you can. If you have strong alcohol, use that. If you have soap and water, use that next. Failing all else, use the cleanest cloth you have with some clean water to wipe off any dirt. The level you’re able to clean will determine the likelihood your character will survive. If you have alcohol, they’re more likely to pull through.
You should be cleaning the chest, the daggar, and the tiny, hollow reed.
Step 3: No time for pain medication, it’s not going to kick in anyways. DO NOT give them alcohol to drink for the pain. Use the smallest blade you have to make a small hole in the chest wall right between the 4th and 5th ribs. They only need to go about an inch if the patient is skinny. Most EMS units today use 3” needles, but not the whole needle is inserted. You probably won’t hear any air movement until you pull the dagger out, so it may take a few tries to get deep enough.
Step 4: Pull the blade out and insert the reed. Once the reed enters the pleural space, air and blood should come rushing out. Relief will be immediate, and the JVD and tracheal displacement should fix themselves in less than a hour.
Step 5: Secure and prevent reoccurrence. That reed needs to stay in place. Use bandages or whatever you have to keep it there. You also need to create a one-way valve to prevent the air from just being sucked right back into the chest cavity through the convient hole you just made. Get a clean rag, soak it in lard, oil, or water if you have to and secure it loosely over the reed. The idea is that when they exhale, the free air in the chest is allowed to escape, but when they inhale, the cloth snaps shut over the reed and prevents air from entering.
Step 6: And now it’s up to their body. The reed should be changed every 12 hours minimum to prevent infection, the one way valve as well. It’s important to note that if you’re using water on the cloth for your one-way valve, you’ll need to keep that wet. Now is the time for pain medication as well, boil the poppy seeds in clean water to make a tea. Poppy contains a similar chemical to morphine, so they will get some relief from this. It’s really hard to drink when lying flat on your back, so drip a washcloth in the tea and let them suck on it.
Your biggest enemy is going to be infection obviously. There are several things you can do to prevent it.
Clean the site. Alcohol or soap and water every 12 hours minimum (do it with the reed change). Make sure you’re cleaning the open wound, but don’t scrub into the chest wall, that’s going to push bacteria further into the wound. The signs of a local infection are:
Red streaks coming from the wound
If infection starts to develop, increase the cleaning to 4 hour rotations, and continue to replace the reed at that time. Signs of a developing system-wide infection:
Both honey and garlic have been clinically proven to have antibacterial properties . Apply crushed garlic and honey to the wound. Garlic also appears to be effective if consumed as well, honey is just topical.
Honey: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609166/
Garlic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458355/
i can’t make this shit up
Pneumonia is a serious complication. Honestly, if they get pneumonia, they’re dead. They will have a high fever, start coughing, and die fairly quickly with a primitive chest tube in place. Sorry. :(
Sepsis is also a death sentence. It’s a system-wide blood infection charterised by a high fever, low blood pressure, then sudden system shutdown and organ death. There’s not a lot you can do without real antibiotics, so avoid this if possible.
Thankfully, the line between a bad local infection and sepsis is not easily identifiable without a hospital (a blood pressure cuff, really) so you can have quite a bit of angst around this and still have them pull through in the end.
What about the broken ribs? Leave them. There’s nothing you can do. Trying to manipulate them with your hands will only make it worse if you’re doing it blind (without X-Ray guidance.)
It’s been awhile… now what? Normally, this patient would be rushed into the OR to repair the hole in the lung. Since you don’t have that, here are a few long-term options.
The lung heals itself neatly. This is totally possible. You’re looking at at least two months though… and it’s a stretch. This character better have plot armor. Note: if you have pierced ears, you know that a hole in the body eventually seals itself off and doesn’t ever heal shut. Same with your makeshift chest tube. Once the lung has healed and it’s time to remove the reed, you may need to scrape the skin of the hole down a little to encourage healing. That’s another few weeks of healing. The lung can regain full capacity, and free air in the pleura will be absorbed into the bloodstream.
The lung heals poorly. As long at the hole in the lung is closed, the body will take care of the rest and absorb the free air. Same scraping for the chest tube site. They may lose use of the damaged lung- some people can learn to live without sections of their lungs but will never be able to do what they used to. It’s important to remember that the broken ribs may have healed in a place where they permanently damage lung function.
The lung never heals. This means a permanent chest tube. The infection will eventually catch up to them, and they’ll die.
Best case scenario survival odds: 60%
Worst case scenario survival odds: 0%
Essentially, if you want them to survive, you can write it in a way it’s medically possible. But they have to fight hard, be strong, and have a healthy body with good fat stores before the accident.
Disclaimer: Although I’m in school to become a medical professional, I’m not one yet. Please don’t sue. Can you even do that from a Tumblr post? I don’t know. All mistakes are mine, and I’m always open to discussion.
‘crimson, thanks for the detailed question. I had so much fun researching this stuff. Hope this helps, and feel free to ask clarifying questions. (Tension pneumo stuff can be really confusing.)