A 34-year-old man was an unrestrained diver in a high-speed motor vehicle collision. The car hit a telephone pole, split the pole in half, and then hit a tree. The patient was found unconscious in the car and required 15 minutes for extrication. On arrival in the ER, the patient had labored breathing, decreased breath sounds in the left chest, and crepitus. A left thoracostomy tube was placed with a rush of air and minimal bloody output. An immediate improvement in respiratory status was noted. Vital signs were otherwise stable (pulse 82, BP 142/88). On examination, the patient had a Glascow Coma Scale of 15 and multiple abrasions of the chest, right shoulder, and lower extremities. Palpable pulses were documented in all extremities, and the brachial blood pressures were equal. Chest radiographs revealed multiple bilateral rib fractures, including bilateral first rib fractures, and a poorly defined aortic arch.