Tag: diana gabaldon

Posted on

Fun Fact: Puncture Wound

Anatomy Def: Puncture wound are deep injuries caused by sharp and pointed objects.

Outlander def: Och! Jamie’s painful bite-site! 🐍🐍🐍

Learn about puncture wounds in Anatomy Lesson #35, Outlander Owies.

Puncture wounds are a specific type of injury caused by sharp, pointy objects such as animal teeth/fangs, metal nails or thorns.  This wound has very specific characteristics: 

      • Small opening(s)
      • Little bleeding
      • Difficult to clean
      • Easily infected

Why are puncture wounds are prone to infection? Because: 

      • Bleeding helps cleanse a wound
      • Little oxygen reaches deep wound
      • Some organisms flourish in low oxygen environments

Important Fact: If the injured person hasn’t had a tetanus shot in the past five years, if the wound is deep, and if it is difficult to clean, a tetanus shot/booster is usually recommended – within 48 hours of the puncture!

Snake: Are you curious about which snake sunk its foul fangs into the vastus medialis of Jamie’s splendid quadraceps muscle?

I am not a herpetologist, but a quick Internet search reveals that North Carolina currently has six types of venomous snakes. ( I assume North Carolina’s current population of venomous snakes is the same as in the 1700s): 

      • Copperhead
      • Timber rattlesnake
      • Pigmy rattlesnake
      • Eastern diamondback rattlesnake
      • Eastern coral snake
      • Cottonmouth (water moccasin) 

Read Diana’s description from The Fiery Cross of the snake:

It was motionless now, quite obviously dead. Still, it took some effort of will to pick the thing up. It was as thick around as his wrist and nearly four feet long. It had begun to stiffen; in the end, he was obliged to lay it across the armload of firewood, like a scaly branch. Seeing it so, he had no trouble imagining how the snake … had escaped notice; the subtle browns and grays of its patterns made it nearly invisible against its background.

Diana’s description and the appearance in the show seems most consistent with the cottonmouth:  Subtle grays and browns, indeed!

Problem is, cottonmouths are only found in eastern North Carolina and not in Fraser’s Ridge territory. So, hard to be sure. But, here is what one looks like. 

Moving on!

Roger’s Efforts: So, how did Roger do at treating the snake bite? 

Weil…….

    • Roger cut the wound! 

He braced himself to the necessary force, stabbed hard and cut quick—two X marks over the punctures, just as the first-aid guides said. The wounds were bleeding a lot, blood pouring down in thick streams. That was good, though, he thought. He had to go deep; deep enough to get beyond the poison. He dropped the knife and bent, mouth to the wounds.

    • Roger sucked out blood and venom!

There was no panic, but his sense of urgency was rising. How fast did venom spread? He had no more than minutes, maybe less. Roger sucked as hard as he could, blood filling his mouth with the taste of hot metal. He sucked and spat in quiet frenzy, blood spattering on the yellow leaves, Fraser’s leg hairs scratchy against his lips. With the peculiar diffusion of mind that attends emergency, he thought of a dozen fleeting things at once, even as he bent his whole concentration to the task at hand.

    • Roger gave Jamie alcohol!

 “I’m pleased to hear it,” Fraser said. “But I think I’ll take a bit o’ the whisky now. Draw the cork for me, aye? My fingers willna grasp it.”

    • Did Roger (or Jamie) apply a tourniquet? Does it matter?
    • Jamie’s sock and boot remain on the injured leg.
    • His heart is above the wound.

Snakebite Experts: Now, what do today’s experts have to say?

Experts recommend snake bite victims, DO NOT:

      • Cut the wound 🚫
      • Suck out the venom 🚫
      • Apply a tourniquet, ice, or water 🚫
      • Give alcohol, caffeinated drinks, or any other medications 🚫

Experts recommend, DO the following:

      • Note the snake’s appearance and describe to medical unit (Roger saved head) ✅
      • Move victim beyond striking distance of the snake (no need!)
      • Lay victim down with wound below the heart ✅ (he did)
      • Keep person calm and at rest ✅ (he did)
      • Cover wound with loose, sterile bandage ✅
      • Remove any jewelry from area that was bitten (no need) 
      • Remove shoes if leg or foot is bitten 🚫 (oops!)
      • Get the victim medical help (Claire’s surgery!) ✅

Grading time! Hum…. 🤔 Looks as if Roger got 5 of 10 possible actions or 50%!  Erm, even grading on a curve, this is a failing grade! 😱

Can Roger’s performance be explained? Should we be upset with Roger?

Yes and not at all!!!

Snakebite instructions from the 1960s, when Roger went back through the stones, were very clear. All first aid manuals listed the same advice. Even Boy Scout manuals contained these instructions:

      • Cut the wound
      • Suck out the venom 
      • Apply a tourniquet

But, science marches on and knowledge improves! We now know what to do and what not to do in the event of a venomous snake bite.

See Roger wrestle with Jamie’s snake bite in Outlander episode 509, Monsters and Heroes!

Roger is a hero….and, Himself is still here! 👏🏻👏🏻👏🏻

Fangs to Roger!

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo Credits: Sony/Starz; www.ncwildlife.org

Posted on

Fun Fact: Cricothyroidotomy

Anatomy Def: Cricothyroidotomy is an incision through the cricothyroid ligament. Wait!!! Whaaaat???

Outlander Def: Puir Roger gets a pipe stem stuck in his neck, not his mouth!

Learn more about the cricothyroid ligament in Anatomy Lesson #42, The Voice!

Here we go! What is the cricothyroid ligament?

Bear with me, here…. In order to understand, we must examine the anatomy of the larynx. This requires a longer Fun Fact than usual – more like a mini-anatomy lesson. 🤓

Larynx: The larynx is what people often call the voice box. Regardless of the name, it is an anatomical wonder formed of a whopping nine different cartilages squished into the upper neck! Together, these cartilages create a hollow conduit for air to pass from nose/mouth/pharynx to the trachea and thence into the lung airways.

We will investigate  two of these cartilages and the ligament that unites them.

    • Thyroid cartilage – shaped like a shield
    • Cricoid cartilage – shaped like a signet ring turned backward
    • Cricothyroid ligament – tissue connecting thyroid and cricoid cartilages

The below figure shows these structures from a frontal view 👇🏻. Notice that the trachea begins directly below the cricoid cartilage.

If the upper airway is obstructed, a temporary hole may be cut in the conduit allowing air into and out of the lungs. 

Bingo! A cricothyroidotomy is an incision in the cricothyroid ligament to reestablish airflow after an obstruction. Yay!

This procedure is also known as a cricothyrotomy. In Roger’s case, the obstruction is caused by swelling of tissues following a short-drop hanging and subsequent strangling 😱.

But, wait! Is there a correct spot to cut the neck? After all, it contains a host of crucial structures: 

    • Carotid arteries (supply blood to most of head)
    • Recurrent laryngeal nerves (cut these and the vocal cords are paralyzed)
    • Thyroid isthmus (bridge) between right and left lobes of thyroid gland (cutting causes major bleeding)

But, of course there is a correct spot! A skilled physician makes the cut using important anatomical landmarks! Let’s use Jamie’s neck to demonstrate👇🏻!

The red arrow points to Jamie’s Adam’s apple, anatomically known as the laryngeal prominence, a mound on the thyroid cartilage. A finger is placed on the laryngeal prominence (red arrow) and then moved downward until it enters a dip. The dip marks the location of cricothyroid ligament (white arrow); the cricoid cartilage lies below. A knife tip can be safely inserted in this dip but only in the midline to avoid injury to the above structures. 

Try This: Lay face up. Relax your throat. Locate your laryngeal prominence. Slowly move finger downwards until you feel a dip, the cricothyroid ligament. It won’t be far, roughly an inch or so. You will also feel a very firm structure below the dip, the cricoid cartilage. Oh! Well done, all!!!🥇

The episode did not show Claire locating the cricothyroid ligament, but obviously, she found it because Roger is still with us!

Claire makes the incision!

The incision will collapse unless it is held open. So, Claire temporarily inserts what appears to be a wooden peg into the cricothyroidotomy.  

But, a wooden peg doesn’t permit air flow, so a hollow tube is needed, STAT! Brilliant surgeon that she is, Claire commanders Mr. Caswell’s imported English pipe, ruthlessly breaking off the hollow stem!

Rinsing it with alcohol to disinfect……

And successfully inserting the cleaned stem into the cricothyroidotomy.

Voilà! Roger breathes through the tube thus bypassing swollen and mangled tissues of his upper airway.

Read about Roger’s throat surgery in Diana’s fabulous tome, The Fiery Cross.  In the book, Claire gives Roger a tracheotomy, not a circothyroidotomy.

A tracheotomy is a bit more perilous because it is done very near the thyroid isthmus, the landmarks are less sure, and the neck must be hyperextended –  not as good for a “hanged man!” 😳

I took a moment, hands on his neck, eyes closed, feeling for the faint throb of the artery, the slightly softer mass of the thyroid. I pressed upward; yes, it moved. I massaged the isthmus of the thyroid, pushing it out of the way, hard toward his head, and with my other hand, pressed the knife blade down into the fourth tracheal cartilage. 

…The cartilage here was U-shaped, the esophagus behind it soft and vulnerable; I must not stab too deeply. I felt the fibrous parting of skin and fascia, resistance, then the soft pop as the blade went in. There was a sudden loud gurgle, and a wet kind of whistling noise; the sound of air being sucked through blood. Roger’s chest moved. I felt it, and it was only then that I realized my eyes were still shut.

…He was breathing, though; she could hear the faint whistle of air through the tube in his throat. Claire had commandeered Mr. Caswell’s imported English pipe, ruthlessly breaking off the amber stem. Rinsed hastily with alcohol, it was still stained with tobacco tar, but seemed to be functioning well enough.

See Roger’s cricothyroidotomy scar in Outlander episode 508, Famous Last Words.

Roger-the-dodger, dodged an awful fate. Kudos to MIL! 👏🏻👏🏻👏🏻

Wow! Dr. Claire continues to impress! 😲

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo credits: Sony/Starz; www.thenakedvocalist.com

Posted on

Fun Fact: Conjunctiva

Anatomy Def: Conjunctiva is a clear membrane covering part of the eyeball and lining inside of eyelids.

Outlander Def: Roger’s bloodied and abused tissues as he gazes at the world through his burlap hood!!! 😥

Learn about the conjunctiva in Anatomy Lesson #30, Aye, Eye – The Eyes, Part 2. 

Conjunctiva is a clear, thin mucous (adj.) membrane of the eye. It is a mucous membrane because, indeed, it contains glands and cells which secrete mucus (n.). This sets it apart from serous membranes that do not secrete mucus.

The conjunctiva has two parts:

    • Bulbar conjunctiva: Covers front part of sclera (“white” of the eye)
    • Palpebral conjunctiva:  Lines inner surfaces of eyelids 

Is the conjunctiva useful? Oh, indeed it is!  👏🏻👏🏻👏🏻 It performs two important functions: 

      • Produces mucus and tears to help lubricate the surface of eye
      • Protect against microbes entering the eye which is vulnerable to the outer world

The conjunctiva contains many small blood vessels that are not especially noticeable unless stimulated to dilate. Dilation allows for increased tear and mucus release. What might cause such a response?

    • Allergens, such as pollen
    • Irritants, such as air pollution, makeup, cosmetics
    • infections
    • Contact lenses
    • Fatigue
    • Hypoxia (reduced oxygen supply)

But, Roger’s conjunctivae are bloody! Why??? This occurs because strangling increases pressure in the conjunctival blood vessels and they swell. The vessels then burst from straining for air and against the rope!

Slowly rewatch the color version of the hanging; you will see blood blooming during his conjunctival bleed. Or, more precisely, subconjunctival bleed, as blood collects between conjunctiva and sclera! 

The special effects are excellent, btw! In Rik’s recent Q and A, he explains he was fitted with special contact lenses and thought CGI was also added. I agree, as I see an increase in conjunctival blood during the footage.

Ergo: If Roger every gets his hands on William Buccleigh MacKenzie!!! 💪🏻💪🏻💪🏻

Fun Fact: Some people worry that a contact lens could wander towards the back of the eyeball and reach the brain. For several anatomical reasons, this doesn’t happen. One major reason is the conjunctiva folds on itself forming a closed pouch all the way around the eyeball. The figure explains 👇🏻.

The L panel shows the bulbar and palpebral conjunctiva from a frontal view.  Note: the bulbar conjunctiva stops at the edge (limbus) of the cornea. It does NOT cover the cornea!

The R panel shows a vertical section through the eyeball. The bulbar conjunctiva is shown as blue and the palpebral conjunctiva is red. A red arrow marks the pocket where the two layers meet. This blind pocket encircles the entire eyeball. Hence, a lost contact lens can only travel as far as the blind pocket. Want to know what to do about a “lost” contact lens? This is a pretty good website!

Try This: Gaze into a mirror.  Locate the clear membrane overlying your sclera. Can you see its tiny blood vessels? This is your bulbar conjunctiva. Gently pull down on the lower eyelid. See the glistening surface? This is your palpebral conjunctiva. Got it? Good job!

Herself explains Roger’s horrific ordeal in The Fiery Cross. Accurate details and explanations accompany her descriptions coupled with fantastic story-telling.  Read the books, folks! 🙏🏻

The others had strangled, slowly. The bodies were twisted, held by their bonds in the final postures of their struggle. One man—one body—was cut down as I rode up, and carried past me in the arms of his brother. There was not much to choose between their faces, each contorted, each darkened in its separate agony. They had used what rope was to hand; it was new, unstretched. Roger’s toes trailed in the dust; he had been taller than the rest. His hands had come free; he had managed to hook the fingers of one hand beneath the rope. The fingers were nearly black, all circulation cut off. I couldn’t look at his face at once. I looked at Brianna’s, instead; white and utterly still, each bone and tendon set like death.

See Roger’s bloody conjunctivae in Outlander, episode 508, Famous Last Words!  ❤️ Roger!

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo credits: Sony/Starz; www.aafp.org