307: Back in the Saddle

It didn’t take long at all for Claire to rediscover the need for her medical skills in 18th century Edinburgh and she started off her new medical practice with a doozy!  I’m glad to finally learn about the patient we’ve seen for 7 episodes now int he season three credits.  I’ve been dying to know who the poor soul was who needed Claire’s trephination skills and today we learned the fate of the victim.

trephination
Property of STARZ

While the procedure Claire performed on her patient appears quite crude, it is actually one of the oldest medical procedures still used in practice today!

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Trephination tools, 1802.  Source: Creative Commons

The injury to his head resulting from his fall onto the stone hearth has caused the exciseman to develop an epidural hematoma.  This is a condition in which a strong blow to the head results in damage to an artery surrounding the brain, leading to the rapid accumulation of blood between the outer protective membrane (dura) of the brain and the skull.  Being quite solid, the skull is not going to bend or swell to accommodate this rapidly accumulating blood, so instead, the brunt of this expanding mass of blood is placed on the brain, compressing delicate brain tissues and increasing pressure to devastating effect.  In response to an epidural hematoma and the resulting compression of the brain, a patient characteristically experiences weakness or paralysis on the opposite side of the body.  Swelling of the brain then causes compression of other parts of the brain, including the third cranial nerve, resulting in dilation of the pupil of the eye on the same side of the head as the injury.

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CT showing an epidural hematoma – note the lens shaped white hemorrhage.    Source: Wikipedia Commons

After hearing the sickening clunk of the exciseman’s skull on the hearth and allowing a moment for the shock of her attack to wane, Claire jumps into action.  It isn’t exactly clear how she so quickly landed on the diagnosis of epidural hematoma.  Classically (though of course not always), a patient with an epidural hematoma will initially have loss of consciousness, then awaken and experience a “lucid interval” before losing consciousness again as the hematoma grows and exerts its effects.  We didn’t see this play out in the episode.  Claire seems to make the diagnosis while he is still unconscious after the initial blow.  In modern times, these are diagnosed on CT scan or are suspected in a patient with a head injury along with a lucid interval and/or characteristic changes in the pupils.  Claire checks the patient’s pupils and states there is still time.  Does this mean the pupils are normal?  If they are normal, what are the clues she is using to deduce that he has an epidural hematoma?  If the pupils are not normal and the left pupil is ominously dilated, there isn’t much time to waste.  Hmm…

To relieve this pressure, a hole must be drilled into the skull to allow evacuation of the blood and relieve the excess pressure within the cranium.  When time allows, a neurosurgeon performs a craniotomy in the operating room.  However, this is quite time sensitive as the hematoma rapidly expands, causing significant injury to the brain.  In austere environments or in situations when transport to an operating room will take more time than the patient has, a burr hole is made to rapidly decrease the pressure.  While this is now done with a specialized hand-held drill rather than a hand crank trephine, the procedure is pretty much as Claire demonstrated.

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Property of STARZ

As Claire readies for surgery and examines her patient’s pupils once more, she finds the left pupil is dilated, pressure is increasing, and she must move now.  She deftly drills a burr hole in the skull to allow the pressure to be relieved and to evacuate the blood.  However, despite her efforts, the exciseman has died of his injury.  Even today, epidural hematomas have a mortality rate ranging from less than 5% to as high as 41%, depending on the patient’s age, the size of the hematoma, the effect of the pressure on the brain, and timing of surgical intervention.  Claire gave the exciseman the best chance he could have had for survival in the 18th century and did what she knew to be morally right thing to do.

A Little Help from the Apothecary

Claire requested laudanum, ground yarrow root, and tormentil from the apothecary. Laudanum, for obvious reasons (though that apothecary seems to stock an amazing formula that works instantaneously!  That patient was OUT quickly!).  Yarrow root and tormentil have hemostatic properties to help stop bleeding, which also make good sense in this situation and my guess is they are for topical application to the wounds.

Herbal medicine was certainly not covered in any depth, if at all, in Claire’s medical education.  I always wonder whether she spent time on her own in Boston over the years learning about herbal remedies, storing those tidbits for possible future (past?!) reference?

I’m sure seeing Claire perform trephination on the exciseman wasn’t everyone’s cuppa tea, but my guess is that if you are reading this, you enjoy this stuff too.  Getting excited for the loa loa, plague ships, and hernias yet to come!   How about you?  What Voyager medical scenes are you hoping make it to the screen?

 

 

 

 

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109: Things That Go Bump in the Night

109: The Reckoning

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source: Starz

Jamie and the Highlanders sneak into Fort William to rescue Claire from the clutches of Black Jack, ready to fight with blades, fists and unloaded pistols.  Given the price already on Jamie’s head, Ned Gowan has warned the men that they must inflict no fatal injuries tonight.  Our Highlanders know how to fight, of course, and rise to the challenge.

The Redcoats are knocked on the head and fall one, by one, by one.

 

hit 2 again
Starz

 

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Starz

Ultimately, Jamie finally knocks out Black Jack with a non-fatal blow to the head. (And the audience groans, knowning what is to come).

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What exactly is happening when someone is knocked out?

Weighing in at approximately three pounds, the brain resides in the protective shell of the skull.  Additional protection is provided by layers of tough membranes called meninges covering the brain as well as cerebrospinal fluid in which the brain essentially floats.  Within the brain are billions of nerve cells, called neurons.  These cells are specialized to allow the gathering and transmission of electrochemical signals.  Some travel short distances within the brain, others might travel as far from the tip of the finger all the way up the arm.  Some neurons control muscle contractions, some are for sensation and others are messengers between neurons.

brain

Mild traumatic brain injury (TBI) or concussion, is a traumatically induced disruption of brain function as a result of an external force.  This trauma causes loss of consciousness, alteration of mental state for up to 24 hours, and post-traumatic amnesia for up to 1 day.

A direct blow to the head sets the brain tissue in motion within the skull, squeezing, stretching and sometimes tearing neurons in the brain.  This leads to varying degrees of abnormality in how the brain processes information.

Loss of consciousness in these injuries is thought to be due to brain edema (swelling).  The brain’s auto-regulatory mechanisms counteract this to protect against massive swelling by limiting blood flow.  The effect of the limited blood flow is accumulation of lactic acid and changes in metabolism at the cellular level in the brain lasting weeks and making the brain vulnerable to further injury during this time.

Symptoms of mild TBI, or concussion, are many:

Loss of consciousness
Amnesia
Altered mental state for up to 24 hours
Headache
Dizziness
Fatigue
Sleep disturbance
Balance problems
Tinnitus (ringing in the ears)
Sensitivity to sound
Difficulty concentrating
Irritability

Symptoms can last months in some cases.
In mild TBI, imaging of the brain with MRI and CT will not show abnormalities but the stretching and swelling of the neurons has a significant impact on the brain’s neurologic circuits.  A brain still healing from a concussion is vulnerable to further trauma.  When a second concussion occurs before the first concussion has fully healed, patients are at risk for rapid and severe brain swelling with catastrophic results – Second Impact Syndrome.  After the first concussion, the brain is still healing and has not yet regained its ability to auto-regulate intracranial pressure and blood flow pressure within the brain.  Remember that the brain is encased within the protective skull so there is minimal room for swelling to occur.  The massive swelling of the brain in second impact syndrome is rapid can lead to death within minutes.

concussiondiagram-2

The awareness of Second Impact Syndrome has led to strict policies and training, particularly in youth sports, regarding return to play after concussion, though the primary way to avoid this will but more research into avoiding first concussions.  It is likely that we will see protective headgear for soccer players in the coming decades.

Another sequelae of repeated concussions is Chronic Traumatic Encephalopathy (CTE).  Athletes and others who have received repeated blows to the head and concussions may manifest memory loss, mood and behavioral disturbances and progress to dementia decades after the trauma.  Some may further develop Chronic Traumatic Encephalomyopathy (CTEM), a disease similar to ALS or Lou Gehrig’s disease causing profound weakness and muscle atrophy.  Many former NFL players have been identified on autopsy as suffering from CTE or CTEM, as sadly there is currently no definitive test to diagnose the condition in the living.  As science advances and we come to be able to identify and diagnose this earlier, it may mean significant policy changes in the future for sports and activities where the risk of head injury is high.

Great advances have been made in the understanding of brain injury in recent decades, leading to heightened awareness of concussion and protective devices for sport.  A far cry from tricorn hats which would have offered no protection from head injury!

tricorns
Starz

 

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