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!

trepanning tools
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.

epidural ct
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.

wound retracted.png
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?

 

 

 

 

Advertisements

304: Murphy’s Sign

Well, this doctor was the patient this week for a wee bit of knee surgery and recovering nicely (but where is Claire and her medicinal whisky when I need her?).  I’m squeezing in a quick post about episode 304 just before the next episode is available on streaming in about a half hour!

What was this pressing surgery that Joe called Claire about?

murphy calcifications.png

Harry Greenbaum has abdominal pain, a positive Murphy’s sign, and calcifications on his x-ray.  Hmmm.  What’s going on?

What is Murphy’s sign? 

Murphy’s sign is a test performed during physical exam of the abdomen that may indicate the presence of inflammation of the gall bladder.  The examiner palpates the abdomen just under the rib cage on the right side as the patient inspires.  During inspiration, the abdominal contents (including the gallbladder) move downward because the lungs are expanding.  If the patient halts inspiration due to pain while the area is palpated, this is considered a positive Murphy’s sign.  See below the location of the gallbladder in the right upper part of the abdomen just under the ribcage:

 

GB.png
Image Source: Wikimedia Commons

What about those calcifications?

Could they be gall stones?  The could, though most gall stones are made up of cholesterol and are not visible on x-ray.  In fact, only 15-20% of gallstones are visible on x-ray.  Today, these are most commonly diagnosed on ultrasound.

The calcifications on Harry’s x-ray could also be a porcelain gall bladder, or a condition when the gall bladder wall becomes calcified due to chronic inflammation, generally associated with gall stones and occasionally associated with cancer of the gall bladder.  This type of calcification is easily seen on x-ray.

Either way, it is time for Harry’s gall bladder to be removed.  Because Joe made it a point to call Claire in Scotland to discuss this, my guess is that Harry is a long time patient of Claire’s and Joe wanted to give her the chance to perform the surgery herself if she would be back in time.  Cholecystectomy, or surgical removal of the gall bladder, is a routine surgery and certainly not anything Joe would need Claire to return for, if there were not other circumstances surrounding this case.

phone and whisky2.png

 

Whew!  Done with a few minutes to spare!  On to episode 305 as this patient continues to enjoy a little bit of downtime recovering from surgery herself!

Cheers!

Outlander images property of STARZ

 

You’ve Got a Little Something in Your Eye…

OutlanderScienceClub_Facebook

A Dram of Outlander Voyager Read-Along  Chapter 60 (LISTEN HERE)

Outlander Science Club

You’ve Got a Little Something in Your Eye… (Listen to the podcast HERE!)

 

Jesus H. Roosevelt Christ,” I said.  “What was that?”

What was that, indeed!  In the search for Young Ian, Claire finds herself doctoring a young man in his twenties who is enslaved at Rose Hall. Lying quietly on a pallet in a dark corner of a kitchen pantry, he doesn’t seem to have a fever nor much distress. In fact, he appears rather well.  Until…

As though in answer to my question, the slave suddenly wrenched himself away from my hand, let out a piercing scream, and rolled up into a ball.  Rolling and unrolling himself like a yo-yo, he reached the wall and began to bang his head against it, still screaming.  Then, as suddenly as the fit had come on, it passed off, and the young man sank back onto the pallet, panting heavily and soaked with sweat.

From Voyager by Diana Gabaldon, Chapter 60

Claire indeed finds a small worm moving underneath the surface of her patient’s eye.

The Loa loa worm and Loa loa filariasis

Nope, this isn’t one of Geillis’ hexes or the product of Diana Gabaldon’s imagination. This is a real disease and Loa loa, with its predilection for swimming under the surface of its victims’ eyes is the stuff of itchy nightmares, my friends!

Loa loa, AKA African eye worm, is a parasitic worm that is passed to humans by the bite of a deerfly. Endemic only to parts of West and Central Africa, Loa loa can only be spread by the bite of the deer fly and cannot be spread person to person.  Claire’s patient at Rose Hall no doubt contracted the illness in Africa before he was enslaved and transported to the West Indies.

africa_en_map
Image: WHO

Humans are the only known hosts of the disease. No other animals are known to become infected with Loa loa.  A deerfly carrying the Loa loa larvae bites a healthy human, depositing larvae into the wound.  Once inside a human host, the larvae grow into adult worms over about 5 months and travel throughout the body.  Adult worms prefer to live between layers of connective tissue, under the skin in the subcutaneous tissue, and between the thin layers of tissue that cover muscle (fascia).  The adult worms can produce thousands of microfilariae (tiny larave) each day and spread throughout the blood stream. The deerfly can then bite an infected human, ingesting the microfilariae, which then evolve into their larval form within the fly, ready to infect the next unsuspecting human again when the deerfly bites again!

l_loa_lifecycle
From CDC – Public Domain

What happens to a person infected with the Loa loa worm?

Many patients with loiasis (infection with Loa loa worm) do not experience any symptoms.  This is more true for those people who live in the endemic regions.  Travelers to these regions are more likely to suffer symptoms.  Most commonly, those infected will develop something called “Calabar swellings.”  These localized swellings, several inches in diameter, are found on the arms and legs are caused by the body’s inflammatory response to the presence of dead worms or the metabolic products of the worms.  Itching occurs around these areas and often all over the body.

Adult worms can be seen moving under the skin, as well as just under the surface of the eye.

UtIRaAp.gif
Image courtesy of Skydmark on Imgur

Presence of the Loa loa worm in the eye causes itching, pain, and light sensitivity.  The worm generally only remains in the eye for less than one week (often just hours) and causes very little damage, since it remains just under the surface, rather than deep within the eye.

Loa loa worms can also lodge in other sites of the body, causing complications in the intestines, kidneys, heart, joints and at times, the retina of the eye.

WWCD?

What would Claire do?  Quickly requesting brandy and a small knife, Claire deftly made a small incision in the sclera of the eye with a sterilized knife. She hooked the needle under the worm and pulled it out.

Did this cure this poor man? Nope.  But it certainly provided relief from the severe eye pain.  Can you imagine the agony of that?

Treatment of Loa loa infection

Surgical removal of Loa loa worms is not curative since it is highly unlikely that a person is infected with a single adult worm. Treatment now is with medication diethylcarbamazine, or DEC, which kills both the adult worm and the thousands of microfilariae circulating in the body. Life-threatening complications including fatal encephalitis (inflammation of the brain) can occur when DEC is used in a person with very high levels of microfilariae in the body.  Therefore, in some cases, other medications are given first to decrease the microfilariae load in the body before DEC is given.  In endemic areas, treatment is reserved for those who have symptoms and also have low levels of microfilariae in the blood.

The good news?  

Loa loa is only passed from infected deerflies to humans in certain rain forests of West and Central Africa.  You cannot become infected with Loa loa from exposure to an infected person – you must be bitten by an infected deerfly to develop the infection.  So, if you haven’t travelled to that region, you are safe!  If you do find yourself traveling to West and Central Africa, there is medication that can be prescribed to prevent infection. In addition, wearing long pants and long sleeved shirts and avoiding times of day when the deerfly is most active will also help prevent infection.

Check out this video showing removal of a Loa loa worm from the eye of an infected patient by a physician in Nigeria.  ***(Not for the squeamish!)

Header Image: NIH NIAID on Flickr

 

Edited to add:  A June 15, 2017 article in Huffington Post explains more about how this disease continues to affect millions in Africa and the difficulties in treating those afflicted by it.