something I’ve seen other whump blogs talk about is flail chest. Can you talk about that and what that hospitalization looks like, especially if there’s lots of chest trauma like punctured lung or other stuff with it?
So a flail chest is what happens when three or more consecutive ribs on the same side of the rib cage break each break in two places. With nothing to hold the lung in its usual shape, the portion under the breaks balloons out of the rib cage and can't take in and expel air properly. These diagrams show what breathing with a flail chest looks like:
Your chest usually expands when you inhale and deflates with you exhale, but with a flail chest, the flail portion deflates on inhalation and expands on exhalation. The affected lung may eventually collapse due to the shunting of air past it to the healthy lung. Pneumothorax may also develop if the affected lung in lacerated. Decreased movement of the affected lung may lead to pneumonia.
Flail chest usually occurs in cases of blunt chest trauma, such as hitting the steering wheel in a motor vehicle accident.
Patients with flail chest present with severe pain at the site of the injury which may radiate to involve the whole chest, difficult and painful breathing, and an inability to get enough oxygen. They will be guarding and splinting the area, which may predispose them to a collapsed lung. The initial trauma that caused the flail chest will have likely also caused other injuries such as pulmonary contusions (bruised lung), punctured or lacerated lung, cardiac contusions (bruised heart muscle), diaphragmatic contusion, cardiac tamponade (like a pneumothorax but in the sac that surrounds the heart), injury to the great vessels (aorta and vena cava), clavicular or sternal fracture, etc.
When whumpee arrives in the ER, they will be put on oxygen (nasal cannula initially, but they will be moved to an oxygen mask if the cannula does not improve their oxygenation) and assessed by an ER nurse. After taking vital signs, the nurse will likely focus on their respiratory and cardiac systems, which will include listening to their heart and lungs with a stethoscope, observing the movement of their chest wall, feeling the pulses in their wrists and ankles/feet, and pinching the tips of the fingers to see how fast the blood flows back into them (capillary refill).
After relaying the assessment findings to the doctor, the nurse will start and IV and pull blood from it for labs. The nurse will also take blood from an artery in the arm; this is a similar procedure to taking blood from a vein, but is more painful and requires the nurse to hold pressure on the puncture site for 5-10 minutes. The nurse will then administer pain medication, likely opioids (morphine) since whumpee is in severe pain. Whumpee will then be helped into a hospital gown and taken for a chest x-ray and a CT scan.
A chest x-ray has the same procedure as any x-ray, but a CT scan is a little different. The patient will be taken to a room an assisted to lay on a sliding table (shown below).
The nurses and radiologists with all be wearing lead-lined aprons, masks, and goggles. The nurse will have whumpee place their arms over their head and may strap their wrists to the headrest to ensure that they don't move during the scan. The scan will last about 10-15 minutes, after which whumpee will be taken back to their triage room.
After the results of the imaging tests come back, whumpee will likely be prepared for emergency surgery to repair the ribs and potentially the lung. They will be transferred to the preoperative unit. If whumpee has eaten anything in past 6-8 hours, a nurse will insert a nasogastric tube and pump their stomach, then administer IV antacids (famotidine). Whumpee will be informed about the surgery that they are about to undergo by the surgeon, asked to sign a consent form that states in writing that they understand the surgery, and wiped down with chlorhexidine wipes. They will have a urinary catheter placed and will be given heavy sedatives (propofol or ketamine). After they are under, they will be intubated and given paralytics (succinylcholine or vecuronium) before being taken to surgery. Thoracic injuries aside from the flail chest will also be repaired during surgery.
When they wake up, whumpee will be in the post-anesthesia care unit (PACU) and will be encouraged to cough to remove intubation lube from their airway (they will have been extubated before awakening). They will be very groggy, but will be intensely monitored and continually assessed for pain and orientation (What is your full name? What day is it? Where are you? Who is the president?), and will be given opioids around the clock. Patients in the PACU are not allowed visitors. When their vital signs and general status are stable, they will be transferred to either the ICU or cardiac telemetry (tele) unit depending on their condition (they can have visitors here).
Whumpee's ribs will be fixed with plates and screws and they will have an incision over the affected area. Nurses will round every 2 hours in the ICU and every 4 hours in the tele unit to take vitals, assess the surgical site, and give meds. Whumpee's catheter will be removed as soon as they can safely walk to the bathroom. Whumpee will be encouraged to cough (while holding a pillow against their incision), deep breathe, and use an incentive spirometer at least once per hour. Find information on incentive spirometry in this post. If they had cardiac contusions or tamponade, whumpee's cardiac status will be continuously monitored.
Whumpee will have pneumatic compression devices on their legs when in bed and will be encouraged to stand, sit in a chair, and eventually walk within 24 hours of the surgery to prevent blood clots and respiratory arrest. When they walk, they will have a gait belt that a nurse or CNA (certified nursing assistant) will hold onto, and a walker. More info on these in this post.
A standard medication list after surgery usually includes:
Pain medications (1-3/10 pain: acetaminophen or ibuprofen; 4-7/10 pain: Percocet or codeine; 8-10/10 pain: morphine or oxycodone)
Blood thinners (heparin, Eliquis, Lovenox)
Stool softeners (docusate sodium, polyethylene glycol)
Initially after surgery, whumpee will be NPO (unable to take anything by mouth) until bowel function returns as evidenced by passage of gas and active bowel sounds in all for quadrants of the abdomen. During this time, they will receive IV fluids and electrolytes. When bowel function returns, they will be given clear liquids (water, broth, clear juice, soda, Jell-O). If they tolerate these, they will be moved to regular food. Most people get to this point within a day of surgery.
If whumpee is in the ICU after surgery, they will be moved to the tele unit when whumpee's doctor determines that they are stable enough. Depending on the severity of their injuries, whumpee may have to stay in the hospital for up to a week or more, but will likely be discharged home after 5 or so days. While home, a home health nurse will visit whumpee a few days after discharge to check the progress of their recovery. Whumpee will also have a follow-up appointment with their doctor a week after discharge.
Alternately, if whumpee had presented to the ER in respiratory distress or failure, they may have to be sedated and intubated until they are breathing spontaneously again. Internal hemorrhage would require blood transfusions.
Happy whumping!
