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We also need the ribcage to function properly, because unless the ribs are intact, they can not rise and fall correctly. We get a situation here called a flail segment, happens a lot on trauma, especially motorcycles, horse riding, mountain bike accidents, where they drop and break a rib in more than one place. When the chest rises and falls, it rises and falls as one solid unit. If you break a rib in one place, the first thing that happens is, as you take a deep breath, the pain is intense. It is extremely painful to expand your chest with a cracked rib. 

It's also extremely difficult to raise your chest with a pulled muscle in your chest from too much coughing or over-stretching and stressing, but you can also get the same pain with pleurisy, because the lungs themselves have three linings, parietal pleura, visceral pleura, and between the two linings is the serous fluid, it's a lubricant. It allows the lung to expand and slide on the two surfaces without any friction being created whatsoever. If you get friction from pleurisy or an inflammation or an infection to the pleural cavity, the two surfaces drag and we get what we call flubber, which when you listen with a stethoscope, sounds like a dragging noise but it's also extremely painful because as the two surfaces drag across each other, they create tremendous pain.

So there are numerous different reason for getting chest pain, never assume chest pain is always gonna be cardiac. It could be ribs, it could be pleurisy, and it could also be a pulled muscle, so we need to rule them in and rule them out. We can rule a lot of fractured ribs in, by slightly pressurising the side of the ribcage or the centre of the ribcage, which will increase the pain, and most of the time, the patient won't even let you touch the ribs if it's a fractured rib. You go to try and assess it and they won't have that. They won't let you do it. That's good enough. You don't have to push on somebody's ribs. If they guard it, if they protect it vigorously, that's enough. That's telling you that rib is so painful, they don't want you to go anywhere near it. But if they will let you touch it and you press on it slightly, that will exacerbate the pain.

Going back to the flail segment, if that rib breaks in more then one place, it will not expand as it should do. Vacuum is what is creating the filling of the lungs, and if a vacuum is created, air will try and always find the easiest route into that vacuum. So, it will try and pull in through the side of the chest wall, rather than go through the airway and the proper channel, because it's easier to pull the wall in that it is to go in through the airway and fill the lung itself. So, what we get is an uneven flail segment where the chest, instead of rising both sides equally, one side rises and one side sucks, so you get an unequal wavy shape or wavy form as you look at the chest, one side will pull in, one side will expand.

Always remember as well to actually look at the chest itself, look for damage, look for bruises, look for holes. Unless we examine properly and unless we do a top to toe check, we are not going to find things like bullet holes, stab wounds, penetration injuries, bruising. All of these can give us clear signs of a problem with the airway and circulation of the oxygen around the body. A fractured rib can go back and puncture the lung, but it will give you external signs like bruising, like potential cuts or grazes, impact zones. You can see and read the external damage on the chest wall, and then that can reflect on what has happened inside the chest itself. And we can confirm that with getting the patient to breathe deeply, using stethoscopes, using percussion. But remember, what goes on the front, can also go on in the back, so we need to also listen top and bottom of the front of the chest, and then also through the back onto the flat bone on the scapular on the back of your back, to listen to the back, and the way the back of the lung is functioning as well as the front.

So, look at the patient. Look at the position they are in. People who are struggling to breathe will assume a position we call tripoding. They will lean forward, hands down on the table, leaning forward so their lungs fall open, using gravity to help them open, and then use ancillary muscles, extra muscles, to breathe. A bit like if you just run around the block, you'll be leaning over trying to gasp your breath. People with breathing difficulties, people with lung injuries, people who have been shot or stabbed, any breathing difficulty, they will assume a tripoding position. Even if they are on the floor, they will have to sit themselves up, so if you come across a patient that's at home in bed, don't lie them flat. If they are propped up on pillows, if they are struggling to breathe, if they've got chest infections, pneumonia, bronchitis emphysema, lying them flat will make the breathing difficulties even worse. The fluid will line the lungs, they'll gasp and they'll force themselves to sit back up again. If you lie them down, they won't lie there for very long at all before they are propping themselves up or tipping over, so we don't make the patient worse. Look at the position, look at the way the patient is acting, and treat the patient properly to manage that airway problem.