Friday, 1 November 2013
My orthopaedic review occurred early on Friday morning. My previously, grossly, swollen shoulder was now thin, bruised and had a very abnormal appearance. A surgical repair was clearly required however, exactly which one could not be determined without an MRI. I was pleased that my shoulder was going to be fixed in terms of long-term function, but disappointed that I had not known this 24 hours earlier as I would have left my chest tube in-situ for my impending surgery.
Given that my left shoulder now felt like a bag of marbles every time I lay back on to the pillows, I knew that the MRI was going to be uncomfortable. The pain specialist did not think that topping up the paraspinal would offer me any additional benefits, as currently my ribs were quite comfortable.
The MRI was planned for 4pm. I had the maximum dose of the two different medications I could use for breakthrough pain as I left the ward to go to the MRI unit. I had only previously had one of these agents at a time.
Getting my left shoulder positioned into the small cradle that had been attached to the MRI bed to optimise shoulder imaging was extremely uncomfortable with my unstable comminuted fractures in my scapula (multiple little pieces pushed into each other). The massive amounts of pre-emptive analgesia must have provided some additional analgesia, but it didn’t feel like it at the time.
Going into the MRI tube was relaxing, because at last nobody was fiddling with my position. As the MRI machine started, it became quite noisy, but nowhere as noisy as I had anticipated based on the experience of others. Red laser beams were spinning around me to allow optimising of the images and for the next 20-30 minutes, I remained in the tube. Throughout this time, I had almost continuous hallucinations, which I am sure were due to my dramatic increase in analgesia. These hallucinations were like the medical/anatomical images that are seen on TV shows like House and CSI Miami. I remember feeling like I was spinning around the optic nerve to bright light at the end; the focus of the vessel pattern was becoming clearer as I got closer. I also remember a hallucination where I was inside a chest cavity as it received a blow from the left with the chest wall deforming under the impact of the blow and the ribs snapping all the way down the front and the back, generating a flail segment. I could then see the lung collapsing as the air escaped from the hole in the lung, caused by the sharp end of one of the many rib fractures.
Discussions with my orthopaedic surgeon that evening confirmed that my AC ligament was intact and my clavicle was intact. Unfortunately, my scapula was so damaged that the Acromion wasn’t connected to any bones, hence I had an unstable shoulder, similar to a complete AC joint disruption. He described some surgery he would perform at 8am the next day to insert some plates and hooks to try and hold this all back together.
I became concerned about the anaesthetic issues for tomorrow’s surgery. Earlier this morning, my paravertebral block had been removed as it had been there for the maximum possible (5 days). I also knew that anaesthetists were extremely uncomfortable performing anaesthesia on patients with a flail chest without a chest tube. I also wanted to know if I could have another paravertebral block inserted to cover the next weeks pain.