Treatment has changed since his last broken rib
Q: My husband slipped while out on his boat and cracked two ribs. He had a broken rib as a teenager (varsity football) and remembers having his chest wrapped, but that's not happening this time. Why not? He's in a lot of pain and it seems like wrapping could help.
A: Although your husband is facing pain and discomfort as a result of the fall he took, those two cracked ribs are proof that the structures of his chest did their intended jobs and helped him escape a graver injury. We're specifically talking about the rib cage, which is an ingenious bit of architecture. It's light, airy and flexible, supports the upper body and allows for a wide range of motion. This includes the ability to take in and expel deep breaths. At the same time, the rib cage is highly effective at protecting important and vulnerable organs and anatomical structures, including the heart and the lungs.
Rib injuries typically fall into three categories: bruised, cracked and broken. They can also include damage to the muscles and cartilage, which are the soft tissues holding the whole structure together. Injuries to the ribs typically occur due to some type of blunt force to the chest, such as a car accident, a fall, being struck by an object or from a physical assault. It's less common, but possible, to injure your ribs while coughing. Ribs are most likely to break at their weakest point, which is the outer curve. Severe injuries can lead to a punctured lung, ruptured aorta or lacerations to the spleen, liver or kidneys -- each of which can be life-threatening.
As your husband has let you know, rib injuries can be extremely painful. In fact, pain at the injury site is the most common symptom. Additional symptoms include pain when flexing the rib cage, either by breathing or moving; muscle spasms; difficulty breathing; audible crunching sounds that arise from the injury site; and a visible change to the appearance of the chest. A rib injury diagnosis often begins with the patient detailing the incident that led to the symptoms. This is followed by a physical examination, and sometimes by a chest X-ray. Unlike the bones of the legs and arms, the anatomical structure of the ribs means it's not possible to immobilize them with a cast as they heal.
At one time, it was common to wrap the chest in an attempt to immobilize the damaged bones. However, this limits the person's ability to breathe deeply and freely, which can increase the risk of developing pneumonia. Instead, treatment is now focused on pain relief, reducing inflammation and rest. This includes the use of ice packs and pain meds (both prescription and over-the-counter), and the avoidance of activities that may stress the injured area.
Depending on the extent of the injury, it can take from six weeks to several months for rib damage to heal. For many patients, once the initial pain is under control, limiting activities to prevent re-injury often proves to be the toughest part of the treatment.
Q: My husband and I were shocked when our nephew was diagnosed with colon cancer. He's only 36 years old. Isn't that awfully young? It seems like we're hearing about a lot of younger people getting this kind of cancer. Why is this happening?
A: Unfortunately, you're correct about the increase in the number of younger adults being diagnosed with colon cancer at this time. And with the recent death of actor Chadwick Boseman from the disease, the disturbing trend has entered the national consciousness. Excluding skin cancers, cancers of the colon and rectum -- collectively referred to as colorectal cancer -- are the third most commonly diagnosed types of cancers that occur in both men and women in the U.S. They account for more than 50,000 deaths each year.
Until recently, colon cancer was not prevalent among younger adults. This had been reflected in the screening guidelines put forth by the American Cancer Society, which had recommended that regular screenings for colon and rectal cancers begin at age 50. But statistics show that younger adults are increasingly affected by this type of cancer. Of the estimated 135,000 cases of colorectal cancer predicted for this year, at least 12% will be discovered in people younger than 50.
As a result, the screening guidelines have since been updated. It's now recommended that regular screenings should begin at age 45. Individuals living with inflammatory bowel disease, and those with a family history of it, are at increased risk of colorectal cancers. They may be advised to start screenings even earlier.
Screening for the disease includes colonoscopies, which are used to identify and, when possible, remove polyps and other growths. Fecal tests can be useful in identifying blood in the stool. Each of these can be indicators of cancer or a precancerous condition. A study published last year found the updated age guidelines for colorectal cancer screenings can prevent about 30,000 potential cases each year and save 11,000 lives. Not all insurance companies are on board with the new guidelines, though, and some patients would have to pay for earlier screenings themselves.
As for why the disease is striking an ever-younger population, researchers still aren't sure. Some suspect changes to behavior, as well as environmental factors, and have launched studies to learn more. Others worry that younger adults are ignoring the physical symptoms that may indicate the presence of colorectal cancer. These include visible blood in the stool, particularly when it's bright red in color; rectal bleeding; persistent sensations of pressure within the bowel and abdomen that are not relieved by a bowel movement; ongoing abdominal pain and cramping; weakness or fatigue and unexplained weight loss. Another indicator is changes to bowel habits that last more than a few days, such as constipation, diarrhea or a change to the shape of the stool. If anyone experiences one or more of these symptoms, it's important to check in with your health care provider. The good news is that, when caught early, colorectal cancers are highly treatable.
Q: Our grandfather was diagnosed with congestive heart failure a few years ago. His strength and endurance have declined a lot, and now he's on oxygen. What are some of the signs that his congestive heart failure is advanced?
A: When someone has congestive heart failure, it means that the heart muscle, along with the structures of the heart, are no longer able to pump enough blood and oxygen throughout the body to meet its needs. An estimated 6.2 million adults in the United States are living with congestive heart failure, according to the Centers for Disease Control and Prevention. The condition cannot be cured, but it can be managed with medication, exercise and lifestyle changes. At some point, however, a patient will enter the end stages of heart failure. For family members, and for the patients themselves, it's important to be able to identify the symptoms.
Shortness of breath, which is often present even in the early stages of congestive heart failure, becomes progressively more pronounced as congestive heart failure advances. A patient often finds they are short of breath not only during activity, but also while at rest. When this occurs, the use of supplemental oxygen, as in your grandfather's case, can help to relieve symptoms. Addressing shortness of breath also helps to allay the fear and anxiety that quite understandably arise when someone is struggling to breathe.
When the ability of the heart to pump blood throughout the body declines, it results in swelling due to a buildup of fluid in the tissues, which is known as edema. This swelling is often first observed in the feet, ankles and lower legs. As congestive heart failure advances, fluid often builds up in the abdomen and within the lungs. Fluid buildup in the tiny sacs of the lungs, known as alveoli, reduces the surface area needed for oxygen exchange. This contributes to shortness of breath, as well.
As the flow of blood to the body slows down, fatigue becomes increasingly common. At the same time, the brain responds by directing the heart to beat faster. This can result in the sensation of a racing or throbbing heart, and may also contribute to feeling weak and dizzy. The patient may begin to have trouble with balance and become weak enough that they have trouble walking, or even getting out of a chair or bed. As blood flow throughout the body slows down, it triggers a number of chemical changes. These can lead to cognition changes, mental lapses, confusion, memory loss and feeling disoriented.
As with many people who are feeling unwell, people living with advanced congestive heart failure often lose their appetites. The digestive system is receiving less blood, which can lead to feelings of fullness or nausea. Along with this range of physical symptoms, many patients will also experience anxiety and become depressed.
For patients whose health care providers believe that they have less than six months to live, the supportive medical and emotional services offered through hospice care may be a good option. A range of supportive hospice services are covered through Medicare.
• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to firstname.lastname@example.org.