101: Soldiers and Shoulders

Episode 101:  Sassenach

From a medical standpoint, the first episode highlights the treatment of two trauma patients: one in 1945 and one in 1743.

101fieldhospwide.png
source:  Starz

Episode 101 opens in an open air World War 2 field hospital with Claire caring for a soldier with an extensive open thigh injury with a spurting femoral artery.  Claire is bare handed and up to her elbows in blood and trying to clamp the artery to prevent the soldier from bleeding to death.

101fieldhospworking
source:  Starz

The mantra of modern Emergency Medicine and Trauma is ABC.   Ensure your patient has a patent airway (A) and intervene as needed, asses whether the patient is breathing  (B) effectively and assist as needed, and evaluate the circulation (C) – heart rate, blood pressure, blood loss.

This soldier appears to have a patent airway without any apparent head trauma and appears to be breathing effectively.  Claire has applied pressure to the wound to stop the bleeding and prevent him from immediately dying from acute blood loss.  She is successful and soon the doctor comes to relieve her and gives the soldier an injection of what seems to be a medication for pain.  This was likely Morphine, possibly Demerol.  Penicillin was another injectable medication used during this time extensively among the Allied Forces, though the depiction on screen suggests the injection brought some immediate relief to the soldier and was more likely an analgesic (pain medication).

The femoral artery is the main blood supply to the leg and trauma to the artery can lead to massive blood loss and death.  For soldiers with such an injury, a significant femoral artery injury would have meant amputation of the leg if blood loss didn’t kill them first.  Advanced techniques for repair of arteries were not yet commonplace.  Today with a similar injury, vascular surgeons can repair these vessels and often avoid amputation.

Gray550
By Henry Vandyke Carter – Henry Gray (1918) Anatomy of the Human Body

 

Later in the episode, Claire meets for the first time an injured Jamie who is under the care of his fellow Highlanders who are discussing his dislocated shoulder.

101clairearrivescottage
source:  Starz

The shoulder joint has the greatest range of motion of any joint in the body and as a result, is the most susceptible to dislocation, accounting for 50% of all large joint dislocations.  In 95-97% of shoulder dislocations, the humerus is dislocated anteriorly, or toward the front of the body.  This generally occurs as a result of a direct blow to the extended arm or a fall on an outstretched arm. Less common are posterior and inferior dislocations.

101shoulderanatomy
© Can Stock Photo Inc. / bluering
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© Can Stock Photo Inc. / alilia

 

…The men’s attention had shifted to a young man crouched on a stool in the corner.  He had barely looked up through my appearance and interrogation, but kept his head bent, hand clutching the opposite shoulder, rocking slightly back and forth in pain.

Dougal gently pushed the clutching hand away. One of the men pulled back the young man’s plaid, revealing a dirt-smeared linen shirt blotched with blood. A small man with a thick mustache came up behind the lad with a single-bladed knife, and holding the shirt at the collar, slit it across the breast and down the sleeve, so that it fell away from the shoulder.

I gasped, as did several of the men. The shoulder had been wounded;  there was a deep ragged furrow across the top, and blood was running freely down the young man’s breast. But more shocking was the shoulder joint itself. A dreadful hump rose on that side, and the arm hung at an impossible angle.

Dougal grunted.  “Mmph.  Out o’ joint, poor bugger.”  The young man looked up for the first time.  Though drawn with pain and stubbled with red beard, it was a strong, good-humored face.

“Fell wi’ my hand out, when the musket ball knocked me off my saddle.  I landed with all my weight on the hand, and crunch!, there it went.”

From Outlander by Diana Gabaldon, Chapter 3

In lean patients with a shoulder that is dislocated anteriorly, the acromion will be prominent and the shoulder will have lost its normal rounded contour.  The arm will be held somewhat abducted (held away from then body) and externally rotated.

Jamie’s dislocated shoulder BEFORE:

101closeupshoulder
source:  Starz

Rupert, so invited, flexed his hands as though about to toss a caber, and picked up the young man’s wrist, plainly intending to put the joint back by main force; an operation, it was clear, which was likely to snap the arm like a broomstick.

“Don’t you dare to do that!” All thought of escape submerged in a professional outrage, I started forward, oblivious to the startled looks of the men around me.

“What do you mean?” snapped the bald man, clearly irritated by my intrusion.

“I mean that you’ll break his arm if you do it like that,” I snapped back. “Stand out of the way, please” I elbowed Rupert back and took hold of the patient’s wrist myself. The patient looked as surprised as the rest, but didn’t resist. His skin was very warm, but not feverish, I judged.

“You have to get the bone of the upper arm at the proper angle before it will slip back into its joint,” I said, grunting as I pulled the wrist up and the elbow in. The young man was sizable; his arm was heavy as lead.

“This is the worst part,” I warned the patient. I cupped the elbow, ready to whip it upward and in.

His mouth twitched, not quite a smile. “It canna hurt much worse than it does. Get on wi’ it.” Sweat was popping ut on my own face by now. Resetting a shoulder joint is hard work at the best of times. Done on a large man who had gone hours since the dislocation, his muscles now swollen and pulling on the joint, the job was taking all the strength I had. The fire was dangerously close; I hoped we wouldn’t both topple in, if the joint went back with a jerk.

Suddenly the shoulder gave a soft crunching pop! and the joint was back in place. The patient looked amazed. He put an unbelieving hand up to explore.

Excerpt from Outlander by Diana Gabaldon, Chapter 3.

There are numerous techniques for reducing an anteriorly dislocated shoulder.  Claire has employed the Kocher technique in which the arm is bent at the elbow to 90 degrees and the arm is slowly externally rotated, keeping the elbow against the body and rotating the wrist slowly out to the side.  Then the arm is lifted and internally rotated to bring the patient’s hand to the opposite shoulder.  The head of the humerus slips back into the glenoid fossa, generally with a satisfying “clunk.”  This method is associated with complications including tearing of the rotator cuff muscles, fracture of the humerus and vascular injury and other methods are now generally preferred.

Jamie’s newly reduced shoulder.  Well done, Claire!

101shoulderfixed
source:  Starz

After she successfully reduces Jamie’s dislocated shoulder, Claire asks for a belt to use as a sling, which Angus reluctantly provides.  She advises Jamie not to move the joint for 2-3 days.  Current medical recommendations for dislocated shoulders include immobilizing the shoulder for 3 weeks in younger patients, such as Jamie, as they are at higher risk for redislocation following the initial injury, but I can’t imagine Jamie would be able to comply with that!

101sling
source:  Starz

 

I’ve always loved Claire in the Outlander books and this first episode, showing Claire in her element caring for wounded soldiers and a wounded Jamie was, in my opinion, a great introduction to the our strong, smart and resourceful heroine.  These Highlanders seem to realize she will be useful to them after seeing her skill with Jamie’s shoulder, wet nurse or no…

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