108: The Lass Needs a Sgian-Dubh!

108: Both Sides Now

source:  Starz

No progress has been made in the search for Claire in 1945.  Frank is growing frustrated and the detective tries to lay it out for him that no body has been found, no signs of struggle were discovered and Claire likely disappeared willingly with the mysterious Highlander.  Mrs. Graham suggests an alternate theory but Frank will hear nothing of it.

source:  Starz

Meanwhile, our newlyweds enjoy a picnic on a rainy day and encounter Hugh Munro who has endured brutality at the hands of the Turks while enslaved in Algiers. He brings news of a man named Horrocks who may be able to exonerate Jamie.

source:  Starz

Hugh presents Claire with a wedding present. A dragonfly in amber.

source:  Starz

As the Highlanders work to make their way back to Leoch, it becomes clear that Claire must learn to defend herself. Angus is chosen to teach Claire how to fight with a knife and using himself and Willie as models, he explains that from the front, she must aim straight up just below the sternum to pierce the heart.

below the sternum
source:  Starz

If approaching from the back, she must stab upwards just below the last rib in order to stab the kidney.  “Straight up.  He’ll drop like a stone!”

right in the kidney
source:  Starz

Indeed these Highlanders know a thing or two about fighting.  A stab wound to the heart in the era before cardiac surgery and trauma centers would almost certainly have been fatal. The kidney stab wound, however, may or may not have been, depending on how much and which parts of the kidney were injured.

The photo below shows the position of the heart in the chest.

The position of the heart within the chest

Stab wounds to the heart carry a high mortality rate even today.  Many victims will die before they can be transported to the hospital.  For those who actually arrive at a trauma center with signs of life with a penetrating heart injury, mortality reaches as high as 80%.

Death from penetrating injury to the heart is generally due to exsanguination (losing massive amounts of blood from the heart), cardiac tamponade (in which the injury bleeds into the pericardial sac surrounding the heart, accumulating enough as to impair the normal filling and pumping of the heart) or injury to the coronary arteries (thus cutting off blood supply to the muscle of the heart itself, rendering it unable to function. Without operative treatment, most patients with a penetrating injury the heart die within an hour.

Illustration of tamponade, showing the pericardiac sac filling with fluid, increasing pressure to the point at which the heart can no longer pump normally (source)

These injuries  require emergent surgical repair.  Those who are too unstable or suffer cardiac arrest before they can be transported to the operating room will undergo emergency department thoracotomy in the ER.  Literally this is “cracking the chest,” and is done in an effort to stabilize the patient enough to transport them to the operating room for definitive repair.  The emergency department thoracotomy will allow control of bleeding by suturing lacerations to the wall of the heart, releasing of cardiac tamponade and allow access for internal cardiac massage (the internal version of CPR compressions for the heart in cardiac arrest).   Once the bleeding has been controlled, any tamponade released and cardiac activity regained, the patient can be transported to the operating room.

Emergency Department Thoracotomy

Of course, shortly following her lesson in the use of the sgian-dubh, Claire deftly employs the skills she has learned and stabs the Redcoat in the back at the location of the kidney.  Indeed he drops like a rock.

knife in the back

Kidney trauma is not quite as fatal as penetrating cardiac trauma.  It very much depends on the location and the size of the injury to the kidney.  As seen below, Angus’ anatomy lesson is right on – just under the last rib stab upward and into the kidney.


In fact, many kidney injuries will heal without surgery.  Modern day management of kidney trauma is very much dictated by CT imaging to see exactly where the injury is located.  Surgical exploration is done for the injury involves the hilum (see image below), injury to the ureters or renal pelvis, or persistent bleeding.

Anatomy of the kidney (source)

Claire has delivered a significant wound to this Redcoat and he seems to have lost consciousness immediately.  Even with massive blood loss from injury to the renal artery at the hilum of the kidney or to the abdominal aorta, he would still be conscious and able to talk and have purposeful movements for a few moments.  However, it is a poignant picture, with Claire lying beneath the dead body of a Redcoat with the knife in his back just as Angus had instructed.

knife in back
source:  Starz

This episode started so sweetly with the newlyweds getting to know one another and having some memorable moments together (wink, wink).  But this is Outlander, after all, and the bliss is short-lived.  Claire is again reluctantly on her way to meet Jack Randall…

claire in wagon 2
source:  Starz

If only she had brought her sgian-dubh along.



O’Connor, J, Ditillo, M, Scalea, T. (2009). Penetrating cardiac injury. J R Army Med Corps. Sep;155(3):185-90.
Shoobridge, J. J., Corcoran, N. M., Martin, K. A., Koukounaras, J., Royce, P. L., & Bultitude, M. F. (2011). Contemporary Management of Renal Trauma. Reviews in Urology, 13(2), 65–72.


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