broken bodies and good luck

Monday, April 9, 2012

“People will choose to blame their circumstances on fate or bad luck. Very few will admit it’s mainly the choices they have made.” Author unknown

Depending upon situation, the perception of luck is very different. The circumstances surrounding the motorcycle crash of Arkansas football coach, Bobby Petrino, provide an example that good and bad luck can exist at the same time for the same person in the same event. The Sparks notes version: while driving his motorcycle with his paramour as a passenger, Mr. Petrino crashes into the ditch. A passerby tries to call an ambulance but Mr. Petrino refuses. He is subsequently taken by private care to the emergency room where he is found to have a broken neck and four broken ribs. The bad luck is that marital indiscretions may exact a heavy cost to Mr. Petrino’s professional and personal life. The good luck is that he survived injuries that could have killed him or left him a quadriplegic.

It is bad luck that he sustained the injuries in the first place but there are significant complications that could have ended his like and it is fortunate that he survived his bad decision to refuse an ambulance. Multiple rib fractures are a sign of significant force applied to the chest and damage can occur to the organs that are protected by those ribs. Breathing can be compromised if the lung collapses or becomes bruised and just the pain of that many broken ribs can prevent the victim from taking deep breaths. Lower ribs protect the organs of the upper abdomen and their fracture can signal a damaged liver or spleen. Upper ribs protect the large blood vessels like the aorta and subclavian arteries that can be torn if enough energy is applied to the body with imminent death a real possibility. And of course, the heart sits in the middle of the chest and is at risk for injury.

When trauma patients go into shock, there are reversible life threatening causes that need to be considered and they are all in the chest. The major disasters include tension pneumothorax (a type of collapsed lung) pericardial tamponade (fluid that collects in the sac surrounding the heart and prevents it from beating), sucking chest wound (most often due to a laceration, stabbing or gunshot wound) and flail chest, where each rib is broken in more than one place and breathing is compromised. A patient who looks good initially can decompensate very quickly.

The brain is connected to the rest of the body by the spinal cord and it in turn is protected from the outside world by the spine. Unfortunately, the cervical spine, the bones in the neck, are at risk for breaking when the body gets thrown around at high speed. There is a reason that first responders, EMTs, paramedics and emergency room staff are careful in moving a trauma victim. If there is significant mechanism of injury to the body, the common mantra is that the neck is broken until it is proven not to be. If a vertebra in the neck is broken and the spinal cord is affected, the patient can become a quadriplegic if the neck is moved. A neurologically intact patient can be damaged if care is not taken to prevent that neck movement.

Not all broken necks involve the spinal cord. Many fractures are stable and need nothing more than a hard collar to act as a splint. Others are unstable and need surgery to repair. It’s not always possible to know in the field or the ER what might be happening to the neck or the rest of the back. The common wisdom is to immobilize the patient in a collar and backboard until the injuries can be sorted out. How tragic if an unstable neck fracture is missed and the patient goes from normal neurologic function to a wheelchair. Presuming the worst is not just an Eeyore mentality; it’s the right thing to do. And it is often difficult initially to assess , especially if the patient has a painful distracting injury…like broken ribs… that prevents them from appreciating their neck pain. Some trauma patients are kept in protective cervical collars for hours and days until the dust settles.

But back to Mr. Petrino. There are lessons to be learned from his good luck that allowed him to survive some significant bad medical decisions. Unless there is imminent disaster, think of exploding cars, drowning or a victim who isn’t breathing, it is best not to move a trauma patient. They can be warmed and comforted but a spinal cord injury should always be a concern. Trauma victims with chest pain or who can’t breathe deeply because of pain need medical attention and it should not be delayed. Paramedics have the skills and tools to perform with lifesaving procedures even before they arrive at the ER. Depending upon what part of the body is damaged, there can be associated life and limb threatening injuries that cannot be diagnosed in a passerby’s car.

In the United States, trauma remains the number one killer of people under the age of 45. While prevention is key, it is important to know what to do when an accident occurs. In so many ways, Bobby Petrino is an example what not to do.

“Luck never made a man wise.” Seneca, Letters to Lucilius

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