Swords Orthodontics
17 Main St, Swords, Co Dublin, Ireland

My Broken Rib: Day 1

So this was the day I broke a rib. Worse still, it was one of mine.

Needless to say, the blogs and the website aren’t meant to be an alternative to a proper orthodontic diagnosis and treatment plan and certainly they’re not meant to diagnose an orthodontic problem so definitely I’m in no position to be advising anyone about broken ribs. If you have a broken rib, go and see a doctor. Ideally one that knows about broken ribs and has a stethoscope and an X-ray machine. And a prescription pad.

 

I gave an interview to Orthodontic Practice magazine in the UK last year and they asked me about my plans and I quoted a John Lennon lyric “life is what happens to you while you’re making plans”. Today was such a day.

It kicked off around 07.15 with a text from a team member to say they were sick and couldn’t come it. They were due to see a full day’s worth of patients, and now those appointments would have to be rearranged and some of the people wouldn’t be able to have their ortho appointment changed – either we wouldn’t be able to get in touch with them or their appointment was so schedule specific, it couldn’t be rearranged. That meant I had a busier than usual day ahead.

The next fifteen minutes went pretty much the same as a thousand days before until the second I went to move from one area of the bathroom to the other and found different parts of me moving in different directions and at different speeds and an instant later I was on the floor and in great pain.

Acute Pain is evolution’s way of telling you “hey, you owe it to the survival of the species to do something about this. Right now.”

 

I’d no doubt I’d broken a rib, and I was aware I’d hit my head on the way down. Neither of these were likely to be life threatening, but I was well aware that there are a few circumstances where certainly they can be and I’m in no way in a position to make that judgement – and that judgement shouldn’t be delayed. There was no one in the house when I called out, so I had to work this one out myself.

A quick assessment of any other abnormal sensation or appearance on my body and then back to the bedroom to get dressed and let the team at Swords Ortho know what had happened –as I’d be relying on them to help me in the unlikely event that I lost consciousness.

WhatsApp Group for safety

I posted a message to a WhatsApp group – “I’ve just had a fall, hit my head and ribs. I’m not too bad, but if I don’t text to this group every 5 minutes please send an ambulance to the house”.

That sort of gave me a safety net to rule out some of the worst case scenarios, and then it was time to consider the options I could see at the time:

  1. There was probably not much point in going to my own regular doctor, as I’d probably need an x-ray so he’d have to send me to a hospital.
  2. I considered calling an ambulance, but the house doors were locked and would need to be sorted. Plus I’d been around enough hospitals to know how that this would lead to a train of events involving some very long waiting.
  3. VHI (Voluntary Health Insurance) run a minor injury “Swiftcare” clinic in Swords, and I figure that might be the happy middle ground – they should be able to either sort me out on the premises or direct me to a bigger hospital if I needed it. I’d been to one of these places before when I needed a non-urgent x-ray, and they were able to do it on a Sunday afternoon.

So I got dressed - which was painful, but not as painful as it would be later in the week. I got out of the house, locked up and then took stock of myself again. Still sore, but no loss of mobility and no difficulty in breathing, and I seemed to be functioning normally cerebrally. I checked in with my WhatsApp group again.

I could have driven to the clinic, but given that there was still an outside chance that I’d a head injury, this might not be a good idea – occasionally that sort of thing leads to a delayed loss of consciousness some time after the event and that would be dangerous if I was at the wheel at the time. So I was on foot unless someone else was driving. At that moment the phone rang and it was one of the team checking in on me – she’d organise the nearest team member with a car to pick me up.

Years ago, I went on course on expedition medicine and one of the lectures was dealing with emergencies and disasters. Obviously this can be scaled down to the individual level. Survival and best outcomes, they told me, depends on effective action and decision making. It might well be sufficient to decide to follow the instructions of people who are trained to deal with the emergency, but just doing what you do all the time and expect things will turn out like they usually do is not a winning strategy.

In a plane crash, there will always be people who put a higher priority on trying to get their luggage out of the overhead compartment than getting off the plane. This will likely end badly for them and people who need to get past them to get off the plane.

And yet, despite the exceptional morning I’d just had, and it was barely 8am, I found myself walking into work, same as every other day. Except this day it hurt quite a bit – in hindsight, perhaps I should have called a taxi right then.

I got to Swords Orthodontics before my team member in the car intercepted me. I didn’t actually need to go into the practice, so I said hello to the first of the crew to arrive (she’d be rescheduling the patients in about 5 minutes’ time) and headed across the road to CAB 2000. We’re at 17 Main St, Swords and they are 18, Main St. It couldn’t be any more convenient. A few minutes later I was walking into VHI Swiftcare at Airside in Swords.

I gave my details to the team at reception and was given a few forms to sign. The service isn’t free, and they explained the prices to me. The price didn’t seem unreasonable. I don’t think I had time to sit down before I was called for triage.

Triage

In these situations, you don’t automatically see a doctor right away. In Swords Orthodontics, a new patient doesn’t see me right away, so I can understand this. You see someone that knows enough to ask the right questions and sort out the right investigations to be able to move your care in the right direction and have all the information ready for the doctor who is going to make the decisions and take responsibility for them.

“You hit your head you say?”

“Yep.”

“What year is it?”

I actually had to think about this for a second, just in case it was a trick question. Then I was asked about what’s in the news. Answer: Brexit.

I was worried that that might not be specific enough for him as it hadn’t been out of the news for the last 4 years at this stage, so I added that there was some sort of scandal about a TD (an Irish member of parliament) voting even though he wasn’t in the chamber at the time. That seemed to connect with the nurse as sufficiently current “and there’s another one at it as well now” he told me.

Blood pressure, temperature and pulse were recorded and I was considered safe enough to be allowed to arrange a urine sample unassisted. Thank heaven for small mercies. As co-incidence would have it, the relevance of all of these things was fresh in my mind as I’d just completed a course in dealing with medical emergencies in dental practice at the weekend  - it’d been organised by the Irish Dental Association and run by SafeHands. I thought it was exceptionally good, and it covered things like blood pressure and pulse and their relation to certain situations.

The doctor arrived and introduced himself. I’m a big fan of a medical journalist/stand-up called Dr Phil Hammond (not to be confused with the UK minister of the same name) and one of his big campaigns is to get doctors to introduce themselves. I was impressed by the attention to detail by the team at the Swiftcare clinic.

He examined me, and a couple of minutes with a stethoscope resolved the first of my worries – there was no clinical indication I had a collapsed lung. He didn’t think the ribs were broken, but even if they were, the treatment was the same as if they were bruised. But first, I’d need a chest x-ray. He offered me a gown but I opted to pull on my t-shirt. I was surprised at how much painful this had become in the last 60 minutes.

The chest X-ray happened within minutes. There were 3 views in total, I think, I had to breathe in deeply at one stage and that was really starting to hurt by then.

Basic treatment for a broken rib

I went back to my cubicle. The doctor came in and explained that he didn’t see a fracture on the X-ray, but the treatment would be the same.

  1. I wasn’t to work for the rest of the week, and
  2. I was to take a load of painkillers that he’d prescribe and
  3. it was important to take a deep breath every few minutes to make sure that my lungs would properly fill with air
  4. the pain would get worse over the next 2-3 days before it gets better
  5. I could expect it to hurt when I breathe, laugh or cough
  6. I could expect this to heal by itself over the next 4 weeks or so

He signed a sickness certificate and a prescription and we were done. I went out to the reception, settled my bill and they called a taxi for me.

When I left the Swiftcare clinic, I had been examined clinically, specially investigated with different x-ray views, diagnosed and a treatment plan had been devised. It was about 90 minutes after the actual accident. I took the cab to the practice – getting the wallet out of my pocket was unusually painful but as I was doing it, the phone rang. This was to notify me that the X-ray had been viewed by a radiologist and they had confirmed a fractured rib. The doctor emphasised again that the treatment would be no different.

On this day, I was very impressed at the provision of care for my condition. It might be different for other people with other conditions, and there is a limited variety to the things that clinic will entertain, but for me, on this morning, it seemed to tick all the boxes. It was time for breakfast, but I’m pretty certain if I’d turned up at the A&E Dept of our local major hospital, I’d be waiting for hours to have the same degree of resolution to the problem. It was time for breakfast.

Pain relief and the broken rib

No one should be in pain. Most broken bones are painful when the ends move against each other, so the classic treatment for a broken bone is

  1. Reduction (ie get the broken parts back together the way they used to be)
  2. Immobilisation (stop the parts moving independently from each other by holding the entire area still, like putting a plaster cast on a broken leg)
  3. Rehabilitation (get the function back to normal in the affected area)

For a broken rib, the first one is usually not necessary unless there has been massive trauma – the muscles between the ribs hold them together unless you’re very unlucky with the break (in serious cases, the ribs have to be surgically plated or pinned together, but that’s not that commonly needed).

The second one is not practical. You can spend 10 weeks with your leg in a plaster cast or your arm in a sling but ribs have to move every time you breathe and that means you can’t take abnormal measures to keep them still. There’d likely be some rehabilitation down the line, but for now, the important thing was the regular deep breath – even if it hurts.

And hurt it will. So that’s where the prescription painkillers come in. For me this was:

SOLPADEINE is 500mg of PARACETAMOL combined with 8mg of CODEINE and 30mg of Caffeine (about the same as a cup of tea or half a cup of coffee). The Solpadeine that I was dispensed was made by CHEFARO/OMEGA PHARMA and they also contain various colourings and gelatin – but they’re not specific about the details on the gelatin, so it might not be suitable for people following a vegetarian, kosher or halal diet.

 

VIMOVO is 500mg of NAPROXEN combined with 20mg of ESOMAEPRAZOLE. Like a lot of things in medicine, you need to do something to counter-act the side effects of the treatment for the main problem. I’ve heard orthodontic lecturers talk about orthodontic treatment as “1 year to fix the problem the patient complained of, and another year to fix the problems that happened when you do”. So the main ingredient here is a non-steroidal anti-inflammatory drug (NSAID), mixed with an accessory drug to counter-act the side effect of stomach ulcers that can happen with them.

The important thing about this medication is that it’s taken regularly so there’s a consistent amount of active ingredient in the body. You don’t wait until you feel the pain to take it, because you’re going to be engaged in an activity that’s necessary but intrinsically painful (breathing).

Breathing with a broken rib

Breathing is a relatively non-negotiable activity for most of us. With a broken rib you can expect a bit of regular pain in the early days but it hurts extra when you breathe deeply. But I knew I was going to be told to breathe deeply because that’s the contemporary advice with a broken rib. You don’t get your chest strapped up to stop the ribs moving.

The first time I’d heard this was in my days as junior member on a maxilla-facial surgery team in Belfast. We had a patient with a broken jaw(which is why I got called in) and ribs. He didn’t go into the cause of the injury beyond saying “I was speaking when I should have been listening” which was not an uncommon sort of history given in the early 90s there. The A+E doctor explained to him about the breathing and advised him to take a deep breath regularly even if he had to grit his teeth.

The reasoning is that without ventilating the lungs and opening up all the little compartments inside them, the secretions that naturally continue in the lungs are in danger of not being cleared fast enough and then they collect and pool in the lungs and give a higher likelihood of chest infection. I had enough problems on my plate, so I’d be working hard to avoid that one.

I had no desire to cook so I had lunch in the cottage and my tea consisted mainly of toast as I took my evening painkillers.

One thought on Post Traumatic Stress Disorder.

As I walked back to the house, I could feel an unsettling in my stomach. I figure I was subconsciously associating the place with harm, even though I wasn’t consciously remembering the events of the morning. I had it again when I went into the bathroom. It was only an instant, and I knew it was happening and once I reminded myself that the place might have a slippy floor but it doesn’t actually wish me harm, I didn’t have the feeling again.

This made me more appreciative of the after effects of seriously distressing experiences that other people have and that even the most trivial of things can make them feel bad or anxious for reasons that might be unfathomable to the rest of us.

I suspect I will still feel cautious when I use the shower.

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As part of Phase One of the National Reopening, Swords Orthodontics is now resuming routine orthodontic treatment.
There will be a few differences in how we do this specifically to deal with coronavirus, but you'll still be getting great orthodontic treatment.
We'll be in touch to reorganise your appointments, please don't attend without an appointment.