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View Full Version : Slash to the stomach, zero to hobble



Bren McDonnall
11-21-2016, 10:48 AM
Have a character who engaged in a saber duel and was slashed deeply across the stomach. The cut wasn't fatal due to some magazine pouches and magazines on the character's belt that acted as a sort of ad hoc armor to blunt the blow, but it was dangerously deep.

The character hobbled around for awhile, concealing the severity until he passed out from blood loss.

Given proper medical treatment (ca. abut 1945 with a doctor on scene), how long before the character might reasonably be expected to be able to get out of bed without tearing stitches?

Character is a 19 year old in prime physical condition going into the fight.

Thanks for any aid.

snafu1056
11-21-2016, 03:33 PM
if it was deep enough he might've had to literally hold in his bowels because those have a tendency to pop out when the abdominal wall "springs a leak". They dont always spill out either, like a classic disemboweling. Sometimes sections will just protrude from the wound like an external hernia, which I would imagine is pretty painful. The aorta also runs through the belly but i think its protected by the intestines (I could be wrong). The wound would have to be really deep to nick that I think.

Bren McDonnall
11-21-2016, 05:35 PM
Doesn't quite go through to the internals. It's addressed in the story.

Just need to figure out how long he's going to be sequestered in the sick bed before he can get back up and start moving around without tearing things open again.

WeaselFire
11-21-2016, 06:09 PM
Doesn't quite go through to the internals.

Then it's not that serious that blood loss should be an issue. The abdominal wall is muscle, it will be painful and may restrict movement, but there are no major arteries or veins in it. You have to get into the intestinal cavity for serious blood loss.

But, have him unable to rise after tripping because his muscles can't pull him up. That gets him noticed, medical attention is bandage immediate, sutures at an aid station, bed rest for a few weeks.

Jeff

GeorgeK
11-21-2016, 07:21 PM
Actually it is possible to bleed to death from just a skin wound. I know of at least one case. The offending surgeon tried to claim that the patient had an unknown bleeding issue until the autopsy showed no known coagulopathies and then they found my operative report and post op notes from a couple years earlier for an unrelated surgery and everything was normal and uneventful. A deep laceration of the abdominal wall that damages the rectus muscle without opening the peritoneum could basically bleed as little or as much as the author wants without further explanation. If there is significant blood loss that may require oversewing the bleeders, or might manage with a pressure dressing. The wound would be expected to be completely healed in 6 weeks or so since there's no involvement of the internal abdominal organs. A young healthy person may be up to very slowly walking around the same day or a day later and possibly back to light duty in about two weeks. When I was 19 I had an emergency appendectomy, minimal blood loss, walking that night, back to school in 3 days and work in 10 days. I was pretty winded by the afternoons for about 3 weeks.



Just need to figure out how long he's going to be sequestered in the sick bed before he can get back up and start moving around without tearing things open again.Since the deeper abdominal fascia is not involved, there's not really any way for a dehiscence to be a major complication. At worst the superficial abdominal fascia might separate but that won't result in any sort of hernia. There might be a gap in the wound that will require moist to dry dressing changes as it ultimately heals by secondary intent. The easiest way to avoid that is to not use any pain medication and let the pain be the patient's guide so they move slowly enough to not unduly stress the incision. That's where I've seen so many surgeons and patients mess up is not understanding that pain is there for a reason. You want enough pain management to be able to get out of bed and do basic hygiene and deep breathing, but not so much that you stress the wound.

MaeZe
11-21-2016, 09:00 PM
Then it's not that serious that blood loss should be an issue. The abdominal wall is muscle, it will be painful and may restrict movement, but there are no major arteries or veins in it. You have to get into the intestinal cavity for serious blood loss.
...
JeffNot true, sorry. Muscles are rich in blood supply, they need to be.

Once again this is a story in need of an injury. How long do you want him to be laid up? Completely transect all the layers of the major muscles and he likely won't be able to function from the get go. Partially transect the muscles and you can tailor the wound to the amount of time you want him incapacitated.

Abdominal muscles (https://en.wikipedia.org/wiki/Abdomen#Muscles)
There are three layers of the abdominal wall. They are, from the outside to the inside: external oblique, internal oblique, and transverse abdominal.[5] The first three layers extend between the vertebral column, the lower ribs, the iliac crest and pubis of the hip. All of their fibers merge towards the midline and surround the rectus abdominis in a sheath before joining up on the opposite side at the linea alba. Strength is gained by the criss-crossing of fibers, such that the external oblique are downward and forward, the internal oblique upward and forward, and the transverse abdominal horizontally forward.[5]....

The way the muscles are layered and divided, they reinforce each other. So you can cut one and you'd be in pain but able to function. The deeper the muscles need to be repaired the longer one would need to take care with the stitches, but as long as you splint the injury you won't tear the sutures open. You might be limited because it would be painful.

So to get up, you roll on your side, hang your feet down and push up to sitting position with your arm. That avoids tension on the sutures.

We have people with open heart surgery up and out of bed the day after surgery. If they do OK they go home in a week. In the 40s when we didn't know as much, people were told to stay in bed longer, but now you try to get everyone up and out of bed the day after surgery unless they are incapacitated such as in a body cast or something.

With tendon and complete muscle transection repairs you do immobilize the repair until considerable healing has occurred. I've never seen that needed with any abdominal surgery.

Deb Kinnard
11-21-2016, 11:17 PM
BTW, "dehiscence" means a repaired wound opening without the patient or doctor intending it to do.

Medicalese, $0.25 or your equivalent in pounds sterling.

ColoradoGuy
11-22-2016, 01:18 AM
I agree with everything George wrote. I've seen some similar, slashing knife wounds in otherwise healthy adolescents. As George writes, transverse muscle splitting incisions are painful. I think his timeline for recovery is about right.

Bren McDonnall
11-22-2016, 02:57 AM
Thank you all very much. This is exactly what I needed.

For background, the wound doesn't so much have to be serious, as it has to seem serious. It's there mainly to explain to the protag that he's not invincible and that he needs to take matters seriously. See, while he's been training for ten years, this is the first time he's ever met a real opponent intent on killing him. He's not particularly worried until he sustains this wound.

He does finish the duel and then spends some considerable time hobbling around, bent over the wound with his forearm pressed to it as the adrenaline rush wears off and he gets weaker. The premise here is that he's concealing the wound so his father won't think him weak. I'm thinking the exertion will be adding to the blood loss. He probably hikes back and forth half a kilometer or so doing various after battle errands before collapsing, and this is after finishing the duel.

I don't specifically say why he passes out when he finally does. It could as easily be exhaustion. The blood loss mentioned in the story is mostly hyperbole from his girlfriend/sidekick who accuses him of walking around bleeding to death without telling anyone. She also claims the pirate (yes, it was a pirate-- an air pirate, no less) had cut him nearly in half.

While they're not in a hospital, they're in a fairly well equipped, well-to-do frontier ranchstead, and there is an experienced combat surgeon present by the time the character goes down.

One question remaining. How would you splint the wound? Would it just be a thing you do as needed, or would they use some sort of persistent device over the wound?

Once again, thanks.

GeorgeK
11-22-2016, 08:51 AM
I don't specifically say why he passes out when he finally does. ...

One question remaining. How would you splint the wound? Would it just be a thing you do as needed, or would they use some sort of persistent device over the wound?

Once again, thanks.A vaso vagal reaction would be a common cause to pass out (take your pick, drop in adrenaline, fright of seeing all that blood...blood gets everywhere and it doesn't take a lot to look like a lot, exhaustion, it doesn't matter and really doesn't need to be explained.)

In 1945 the standard would have been to sew the wound. They didn't have surgical staples and the tapes that they had did not remain in place when wet and since blood is wet... Silk would have been the most common suture and a saber wound would have to be considered potentially dirty so it would not be a water tight closure. Antibiotics, depending upon one's location might not have been available. Drains were fairly primitive so a closure tight enough to heal but loose enough to drain pus would have been the most likely goal. The stitches would be probably a little over a centimeter apart and probably every third or so would be a mattress suture rather than a simple suture. Those are easier to to show than to explain, so you can google it. The mattress suture is the standby as a reinforcing suture that is far less likely to tear out. Had the cut gone into the abdomen then you are potentially into retaining sutures.

Apply clean cotton dressing to the wound, hold it in place with either tape if you have it, or a wrap around the abdomen. Wash the wound and change the bandage any time the wetness soaks through or three times a day, whichever is more. I'd expect the wound to be dry in a week. The drainage that soaks into the gauze (assuming no pus) will start out reddish then pinkish with flecks of brown and then yellow with flecks of pink and then crusts over. The smell of a mostly clean wound such as that is not too different than 3 day old hamburger in the refrigerator

It's sewing and washing and bandaging. It's not splinting. Splinting would be if you applied some rigid object over the wound to restrict movement. I suppose you could theoretically do that with an abdominal wound with a corset and probably a few patients found it helped, but AFAIK that was never considered standard of care. Now thinking about it, it would probably work as a pressure bandage but you'd have to make sure not to make it too tight. You want that wound to be able to drain.

Bren McDonnall
11-22-2016, 10:36 AM
Thanks. When I looked up 'splinting an abdominal wound' they talked about holding pressure against the stomach above and below the wound while coughing or sneezing. That was what was confusing me.

The place was pretty decently equipped. They were several hours from the nearest town, and the owner did most of his own rough and ready doctoring of injuries, so he'd have most of the things needed in place, short of blood or plasma or the like.

The original wound treatment was done by the combat experienced local doctor who was on scene due to this having been essentially a militia engagement with wounds an almost guaranteed byproduct.

There is a small bit about tearing a stitch, and the repair is done with silk thread and a curved needle.

Thanks for all of the detail, it will ad much depth to the story. And thanks for making me look up vasovagal. I always enjoy using new words. Additionally, working the term into (less than) polite conversation should provide some hylarity.

I know I said one more thing in the last post, but... er... one more thing. Would the area (just below the ribs) bee thick enough that a non penetrating wound would require more than a single layer of stitches? I ask because I had a dog once who'd suffered one of those merry mishaps dogs are prone to, and they sewed him up with two layers of stitching.

Again, thanks. This info is invaluable.

GeorgeK
11-22-2016, 03:49 PM
Thanks. When I looked up 'splinting an abdominal wound' they talked about holding pressure against the stomach above and below the wound while coughing or sneezing. That was what was confusing me.

The place was pretty decently equipped. They were several hours from the nearest town, and the owner did most of his own rough and ready doctoring of injuries, so he'd have most of the things needed in place, short of blood or plasma or the like.

The original wound treatment was done by the combat experienced local doctor who was on scene due to this having been essentially a militia engagement with wounds an almost guaranteed byproduct.

There is a small bit about tearing a stitch, and the repair is done with silk thread and a curved needle.

Thanks for all of the detail, it will ad much depth to the story. And thanks for making me look up vasovagal. I always enjoy using new words. Additionally, working the term into (less than) polite conversation should provide some hylarity.

I know I said one more thing in the last post, but... er... one more thing. Would the area (just below the ribs) bee thick enough that a non penetrating wound would require more than a single layer of stitches? I ask because I had a dog once who'd suffered one of those merry mishaps dogs are prone to, and they sewed him up with two layers of stitching.

Again, thanks. This info is invaluable.Yes, it would be normal to close the external fascia in a separate layer compared to the skin, but that too would not be a water tight closure and most likely would also involve a few mattress sutures. You only do water tight closures on sterile wounds, not clean and certainly not dirty wounds

Bren McDonnall
11-22-2016, 04:37 PM
Got it. Thanks.