Personal views: Learning the hard way
Authors: Bruce Finlayson
Journal: BMJ (2000)

Ihave been a keen motorcyclist for as long as I can remember. I passed my motorcycle test at the first attempt at the age of 17. I believe I am a very safe rider (don't we all?), and I ride defensively. Until this event I had never been in a situation that caused me alarm, nor had I been even close to an accident.


I was negotiating a roundabout close to a United States air base and saw a huge American left hand drive four wheel vehicle with Mafia-style tinted windows waiting to enter the traffic. I had almost made it to my exit, when the driver pulled out sharply. Everything went into slow motion as the inevitable collision occurred. I saw the kerb and the road coming to meet me, and struck my helmet as I landed. I felt the left side of my chest hit the road and the kerb as I slid along, still astride the machine. I felt so helpless, but can clearly remember thinking as I came to a halt that I could still think, feel, and move. I lay there going through a mental checklist of airway, breathing, circulation, disability. 


I recall thinking of excuses and reasons for not going to sleep



I was aware at the time that my chest hurt when I inhaled and that my left leg was trapped. Petrol was pouring on to the road and I managed to lift the bike with some difficulty. I remember thinking, “My leg's not broken—that's a bonus.” While waiting for a rescue vehicle, I became aware that my chest was steadily becoming more painful.

The journey back to base town (some 40 miles in a poorly sprung transit van) was very uncomfortable. I recall feeling intermittently dizzy and short of breath. I surreptitiously checked that my trachea was still in the midline. By the time we reached the motorcycle shop, I was in severe pain. My wife picked me up and took me into my own accident and emergency department. To my astonishment the chest x ray was normal, and, against advice, I decided to go home. “I have some ibuprofen at home, I'll be all right.”

The first night was unbelievable. I had to plan ahead before I moved, breathed, and even before I got out of my chair. I was able to sleep fitfully for a few minutes at a stretch, waking every time with severe pain and stiffness in my chest, so much so that I became afraid to sleep, because the pain was always worse on waking.

The ibuprofen was completely useless. I remember sitting in despair as I felt my ribs crepitate with every breath. The only satisfactory pain relief came from a mixture of diclofenac and co-proxamol, taken regularly as soon as possible after the recommended interval.

It was a full week before the pain started to ease. During this time I seldom rose from my armchair. I was afraid to breathe or cough. I could not even blow my nose. I knew that regular, deep breathing was important, too, but forget it. The worst moment was watching Billy Connolly on the television five days after the injury. I started to laugh uncontrollably and had to leave the room. I stood in the kitchen leaning over the sink, clutching my side helplessly and hopelessly for several minutes, alternately laughing and shouting with pain. My daughter has since given me the video as a reminder.

It was two weeks before I was able to gingerly blow my nose, and I decided to return to work. After three weeks I was able to cough and laugh with care. I could not perform cardiac massage for four weeks and I was unable to sneeze without pain at seven weeks.

For three weeks my ribs continued to click, and I could not lie down. For the whole of this time I slept in my trusty chair. I was afraid to close my eyes, knowing that if I slept, I would wake repeatedly in the night, and that the pain and stiffness would always be far worse on waking. I recall thinking of excuses and reasons for not going to sleep.

This experience has opened my eyes and my mind. I deal with patients in pain every day and I always believed I was sympathetic and proactive in their management, but I now believe that I need to take pain into consideration far more seriously. I was able easily to cope with the initial pain once I had the analgesic regimen sorted out, but it is difficult to describe unfelt the feeling of despair when the pain simply does not go away, and your every physical action has to be planned in advance. The sheer physical exhaustion from lack of sleep was far worse than anything I remember from my early training years.

I have always given patients with chest injuries advice to breathe deeply and to support their ribs with their hands when they cough; I now know how naive this advice is.

There is one silver lining, however. I have completely cleared the backlog of unread journals and papers and I am contemplating applying for continuing medical education credits.