210: When Nothing Can Be Done

210: Prestonpans

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STARZ

After six years of combat nursing in the Second World War, Claire knows what awaits and she is as prepared as she can be.  She has collected what she can in the way of medical supplies including strips of bandages sourced from petticoats and shirts, needles and thread, honey water for hydrating the wounded, alcohol for sterilization, laudanum and whiskey for pain relief and fortunately the medical bag of a Doctor MacPherson which has been left behind, containing useful medical instruments.  Along with her crew of willing and not-so-willing volunteers, she stands in nervous anticipation for an influx of wounded soldiers.

angus carries rupert
Selfless Angus – STARZ

Ever the stoic Highlander and loyal friend, Angus carries Rupert to the field hospital, where he can be cared for by Claire and her ready crew.  Rupert has sustained a large laceration to the left side of the chest.  The wound involves the skin and soft tissues of the chest wall, but remains superficial to the ribs and the vital organs and blood vessels of the thorax.  After a dose of what is likely laudanum for pain, Claire sutures the wound closed.  If he can avoid an infection in the wound, Rupert will recover.

As Murtagh so keenly notes,  “Dinna fash yerself, that blubber no doubt protected his innards.”

Rupert’s wound is actually the same type of wound Jamie sustained in Dragonfly in Amber in the Battle of Prestonpans:

It was a saber-slash, slanting across the ribs.  A lucky angle; straight in and it would have gone deep into the intercostal muscles between the ribs.  As it was, an eight-inch flap of skin gaped loose, red beginning to ooze beneath it again with the release of pressure.  It would take a goodly number of stitches to repair, but aside from the constant danger of infection, the wound was in no way serious.

From Dragonfly in Amber by Diana Gabaldon, Chapter 36.

For the TV adaptation, Rupert sustains this wound rather than Jamie.  The contusion and potential kidney trauma resulting from four-hundredweight of horse stepping on his flank will be plenty for Jamie to deal with for now (though if the show stays true to the book in this regard, he will be fine, pissing contests notwithstanding…).

As the episode progresses, subtle clues suggest Angus isn’t doing so well himself.

Angus is quite subdued and without the normal witty banter we have come to expect from him even in the most trying of times.  He begins to complain of headache and soon after, collapses to the floor.

internal bleeding
Ecchymosis (red/blue/purple discoloration of the skin) – a sign of internal hemorrhage / STARZ

What happened?

On the battlefield, Angus saves Rupert from a charging Redcoat and moments later is blown to the ground by a cannon blast immediately behind him.

angus in blast
Cannon blast just behind Angus as Rupert watches on / STARZ

Blast injuries result from explosions and have the capability to cause significant, life-threatening injuries.  What used to be a pattern of injury seen primarily on battlefields, blast injuries are sadly becoming more common in the civilian population as the result of terrorist acts.

Blast injuries are categorized by the mechanism with which the explosion causes injury:

Primary blast injuries are injuries caused by the direct effect of transmitted blast waves.  The lungs, bowel and middle ear  – air filled areas of the body – are the areas most susceptible to this type of injury.

Secondary blast injuries are those injuries sustained when a vicim is struck by airborne debris from the blast.

Tertiary blast injuries are caused by high-energy explosions when the victim is propelled through the air and strikes other objects or the ground.

Quaternary blast injuries are the injuries that occur as a result of all other forces, such as a resultant fire and building collapse following an explosion.

Angus has suffered a primary blast injury to his abdomen, which can cause perforation of the intestines, hemorrhage, lacerations of the solid organs such as the kidney, liver and spleen, and shearing injury to blood vessels throughout the abdomen.

angus from above with group at end
Angus’ final moments, surrounded by Claire, Jamie and Dougal / STARZ

Angus dies of massive internal bleeding in Claire’s arms, with his last words, “Save me, Mistress.”  She is helpless to save him.  There is nothing to be done, even if he had sought her help immediately.  The knowledge, tools and resources needed to surgically treat the trauma he sustained would not be available for two more centuries, and even today this injury would carry a substantial risk of death.  There is nothing Claire can do but provide comfort as he takes his final breaths.

Perhaps sensing the severity of his wound, Angus chose to spend his final moments by the side of his trusted friend, keeping watch over Rupert.

angus will watch ruperts belly moving
Keeping vigil at Rupert’s bedside, watching him breathe / STARZ

It was truly devastating to lose a member of the Highlander family.  The battle might have been won but not without heartbreaking cost.

“War leaves a bitter taste, no matter the outcome.” – Jamie Fraser

smiling angus
STARZ

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

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209: The Invisible Wounds of War

209:  Je Suis Prest

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The field hospital at which I was stationed had been shelled three times.  Even knowing that the flimsy walls of our temporary structures would not protect us, still doctors, nurses and orderlies had all dashed inside at the first alarm, huddling together for courage.  Courage is in very short supply when there are mortar shells screaming overhead and bombs going off next door.

From Outlander by Diana Gabaldon, Chapter 7

combat nurse
STARZ

Claire spent six years as a combat nurse in the second World War.  In episode 209, the sights and sounds of men preparing for battle trigger terrifying flashbacks to her time in the war and she is seen reliving the trauma she has no doubt tucked away deep in her memory.  As a combat nurse, she would have spent her days caring for soldiers suffering horrendous injuries as well as the more mundane, as we see with her flashback to her time educating soldiers about trench foot.  She would be building relationships with the same men and women who would later be sick and seriously injured and in her care.  She would have witnessed innumerable tragic deaths, while often fearing for her own life.  When the war finally ends, Claire finds herself with only a brief time of peace and reunion with Frank before she is once again in harm’s way.

Since her arrival in the 18th century, Claire has suffered what seems to be a lifetime of traumas in the form of war, violence, assault, arrest and imprisonment, narrow avoidance of execution, witnessing the torture of her husband, and the devastating death of her daughter.

Claire holds deep within a long history of trauma.

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STARZ

Shell Shock and the World Wars

The psychological distress experienced by soldiers was first dubbed “shell shock” during World War I.  Physicians used the term to describe the “dazed, disoriented state many soldiers experienced during combat or shortly thereafter.”(1)  The condition was thought to be brought on by concussion and physiological damage caused by exploding artillery shells.  However, military physicians noted that the same symptoms were seen in other soldiers who had not been in close proximity to exploding shells and opinion shifted, with many contending that shell shock was “a variety of cowardice or malingering” and those who “cracked” under the pressure of war were considered weak.

After WWI, Sigmund Freud argued that shell shock was psychological in origin, recommending psychoanalysis for treatment.  The idea that brain injury from exploding artillery shells led to these symptoms fell out of favor and the opinion that the condition affected the psychologically “weak” persisted.  During WWII, draft boards attempted to “weed out” those deemed psychologically unfit to fight, finding over 1 million men ineligible to go to war.  Despite this, in the European theater, the US military had a rate of psychiatric casualties of 102 per 1,000 troops.(1)

Overall in WWII, 25% of US military casualties were caused by psychological war trauma.  The rate was approached 50% for soldiers engaged in long, intense fighting.(2)  Seeing that so many suffered these effects, despite already excluding over 1 million men in the screening process, opinion among most in the military began to shift to the acceptance that combat fatigue was not evidence of cowardice or pre-existing mental illness.

1,393,000 soldiers were treated for battle fatigue during WWII.  Treatment was often focused on a few days of complete rest, with quick return to the front lines.  50-70% returned to combat within three days.  Other treatment modalities included the administration of sodium pentathol (dubbed “truth serum”) to induce soldiers to “re-live their repressed battlefield experiences and thus reach a catharsis.”(2)  Other physicians found that providing liquor during debriefings was beneficial to the troops.  Some were treated with electric shock in an attempt to “jolt” the veteran out of his emotional turmoil.  Others were treated with large doses of insulin which dropped their blood sugar severely and caused a comatose state.  In the 1950s, some WWII veterans were even subjected to lobotomy, or surgical severing of the frontal lobes of the brain, in an attempt to relieve their psychological symptoms.  Whether dubbed shell shock, psychoneurotic disorder, anxiety neurosis, character disorder, or combat exhaustion, very little was understood about what would come to be known Post Traumatic Stress Disorder.

 

Defining PTSD

In 1980, after experience with troops returning from the Vietnam War, the American Psychiatric Association defined PTSD and published diagnostic criteria.

Post Traumatic Stress Disorder, or PTSD, is now defined as a mental disorder that can develop after a person is exposed to a traumatic event, causing at least one month of symptoms including a variety of the following:

  • Re-experiencing the trauma
    • flashbacks, bad dreams, frightening thoughts
  • Avoidance symptoms
    • staying away from places, events or objects that are reminders of the trauma
    • feeling emotionally numb
    • feeling strong guilt, depression or worry
    • losing interest in activities that were previously enjoyable
    • difficulty remembering the traumatic event
  • Arousal and reactivity syptoms
    • easily startled
    • feeling tense or “on edge”
    • difficulty sleeping
    • angry outbursts
  • Cognition and mood symptoms
    • trouble remembering key features of the traumatic event
    • negative thoughts about oneself or the world
    • distorted feelings like guilt or blame
    • loss of interest in enjoyable activities

The manner in which PTSD causes these symptoms is not yet understood.  Interestingly, MRI studies have shown decreased volume in key parts of the brain in patients suffering from  PTSD.  The hippocampus is involved in creating new memories and retrieving them in response to relevant stimuli.  The amygdala helps to process emotion and plays a role in fear response.  Both have been found to be smaller in PTSD patients.  These findings have raised the question of whether PTSD causes these brain changes or if those with these differences are more susceptible to PTSD, thus opening the door to research into strategies for prevention and treatment.(3)

1511_The_Limbic_Lobe
Location of the amygdala and hippocampus in the brain / source

Treatment today for PTSD includes cognitive-behavioral therapy, antidepressant medications, or a combination of both.  Many resort to self-medication with drugs and alcohol to dull their crippling symptoms of PTSD, only to battle addiction as well.

 

The Impact of PTSD Today

In the US, 3.5% adults have PTSD in a given year and approximately 9% will develop it at some point in their life.  Rates are higher in regions of armed conflict.  11-20% of veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffer from PTSD in a given year.  About 12% of Gulf War (Desert Storm) veterans will have PTSD in a given year.  It is estimated that about 30% of Vietnam Veterans have had PTSD in their lifetime.(4)

Combat veterans are more likely to have suicidal thoughts, often associated with PTSD, and are more likely to act on a suicidal plan.  They are less likely to seek the help of a mental health professional for fear of social stigma or “appearing weak.”(5)

Each day, 22 US veterans take their own lives.(6)

There is significant work to be done to fully understand how PTSD works, why it happens and what we needs to be done to prevent it and help these patients.  Public awareness and understanding of PTSD and its effects is vital.   Bravo to the Outlander team for this compelling depiction of PTSD, and in a female veteran no less!

Resources for those suffering from PTSD and those who care for them:

Veterans Crisis Line

Stop Soldier Suicide

Real Warriors Campaign

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

PTSD

 

1.  Scott, WJ.  “PTSD in DSM-III:  A Case in the Politics of Diagnosis and Disease.”  Social Problems.  37 (1990): 294-310.

2.  http://www.pbs.org/perilousfight/psychology/the_mental_toll/

3.  Morey RA, Gold AL, et al.  “Amygdala Volume Changes in Posttraumatic Stress Disorder in a Large Case-Controlled Veterans Group.”  Arch Gen Psychiatry. 2012;69(11):1169-1178.

4.  www.ptsd.va.gov

5.  Sher L, Braquehais MD, Casa M.  “Posttraumatic stress disorder, depression and suicide in veterans.”  Cleveland Clinic Journal of Medicine. 2012. 79(2): 92-97.

6. “Office of Public and Intergovernmental Affairs.” News Releases. VA Office of Public and Intergovernmental Affairs, 1 Feb. 2013. Web. Retrieved from www.va.gov/opa/pressrel/pressrelease.cfm?id=2427.