Shanksteps #155
There was hushed sounds in front of the OR doors. I turned on my headlamp. A group of about 15 people are huddled around a gurney. On the gurney is a 30 year old man, speaking in a hoarse voice. At each word blood bubbles from the side of his neck. He is conscious and responding appropriately. Blood also bubbles from his nose and mouth. A pool of blood is under the head of the gurney. His blood pressure is low and this pulse high. He is from a village about a half hour away by motorcycle. He had a stab wound entering the left lateral neck and exiting the right anterior neck. So the medical students and I took him to the operating room.
He was bleeding more after being moved. I opened his neck along the midline, low near his sternum. Dissected down to the trachea, and made a window into the trachea. A large tracheostomy tube was inserted and sewn in place. He was now breathing better, but still bleeding when we let up pressure on his neck. Along his left sternoclidomastoid (SCM) we opened the skin. I dissected down to the internal jugular vein and noted that it was nearly transected. His blood pressure was quite low by now and we waited for him to get more fluid so that his pressure came up. We also were waiting for Kanas (the lab tech) to come in and do a groupage sanguine (blood typing). The vagus nerve was dissected from the vein leaving it towards the carotid artery. We controlled the bleeding and then explored the area. It seemed that the knife had traversed the thyroid cartilage and exited the other side of his neck. I could not identify any other injuries so I left a drain in his neck, closed the SCM, and closed the area that I had opened leaving the stab wound open.
Three days after the surgery he was looking much better. The facial swelling that had been present after surgery had subsided and I let him start to drink water. The day was busy. I made rounds on the surgical/maternity ward with about 20 patients. Then saw about 10 patients in clinic, treating their pneumonia, typhoid, malaria, rash, skin infection… I then started the ventral hernia repair. While in this surgery, the nurse came to tell me that Matakon (the man who had been stabbed in the neck) had liquid coming from his neck. I tried to determine, by his description, if it was pus, water, or what kind of fluid. I was unclear after discussing it. So after the surgery I went back to see him again. I asked Matakon if the water he drank came out his neck, he said yes. So I ask him to demonstrate. He took a big gulp of water, and out the left side of his neck gushed the water he swallowed! I returned to clinic sad for this man. I saw another 6 patients that were waiting and headed home that evening. I tried to look up neck wound in the ENT book and Trauma books that I had and all they said for esophageal perforation was repair it and put a muscle flap in between esophagus and trachea.
The next day we took him back to the operating room. I reopened his neck, identifying the vagus and recurrent laryngeal nerves. Going next to the carotid artery and the trachea and behind to the esophagus. After quite some time of tedious dissection I found the hole in his esophagus. I closed the hole, then placed a sternohyoid muscle onto the repair. Next we placed a gastrostomy tube (stomach feeding tube) into the abdomen.
He is now 4 days after that surgery. We are often doing his tracheostomy care as the nurses are getting used to it. Fortunately this one has an inner canula. This can be taken out and cleaned then reentered to its position. We are feeding him via the G-tube. With many days of IV fluids and antibiotics and surgeries his bill has become huge, around $380. The one who stabbed him in the neck is in jail, his older brother! Please help him by praying for his recovery and healing of his extensive injuries. Greg
