1. T.Trian
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    T.Trian Overly Pompous Bastard Staff Supporter Contributor

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    A Few Questions for Docs/Nurses about Disembowelment and Healing / Consequent Health Problems

    Discussion in 'Research' started by T.Trian, Dec 10, 2013.

    So, my MC ends up in a tussle with a psycho (let's call her X), who has pinned down the MC and uses a knife to make a horizontal cut in the MC's gut (I was thinking a bit below the belly button), about 13cm/5" wide, about 9cm/4" deep. Mind, these lenghts and depths aren't important, e.g. if the depth is so deep that it causes the blade to slice up the MC's intestines, I'll make it a bit shallower or if it's not deep enough to clove the abdominal muscles in twain (sorry, I love that expression, had to use it), I'll deepen it. The MC is very fit, so her abs are pretty thick, but her body fat percentage is also very low (around 10%), so there's no flab to cut through. X has sliced up / tortured several people to death, so she has a pretty good grasp on human physiology although she has no medical training. Lots of combat training though.

    Anyway, X then proceeds to stuff her hand / a few fingers into the cut, grabs hold of the MC's small intestine (I'm assuming that's what she'd come across first?), and pulls out some of it (say, 30cm / 12" or some such, this length isn't important either, its effect is, so I can change the numbers here as well), then leaves the MC there. At this point, the MC also has also sustained some other injuries, not sure how much they would affect her survival:
    -minor stuff like bruises, cuts from shards of glass etc.
    -a nasty concussion (first from a concussion grenade, then from getting beaten up by X)
    -her right hand was cut off just below the elbow earlier in the story, so it's mostly healed or at least not a serious danger to her health at this point, but I'd imagine this makes giving herself first-aid more tricky

    As I've written it so far, once X leaves, the MC gives herself a shot (or two) of morphine and tries to hold in the intestines. Finally, the questions:

    1. Do humans have nerve-endings (or whatever they are) in the small intestine, i.e. does she feel pain if someone touches the exposed intestine?
    2. How bad would it hurt? I mean, is it knife-stuck-in-your thigh -level of pain or white-hot-poker-in-the-anus -pain? Just trying to gauge whether she'd be screaming her throat hoarse or would she be able to function on some level despite the pain? I'm leaning towards the latter since I've read a few accounts of people who were disemboweled (guts hanging out) and survived (one soldier even jumped off an enemy ship, swam to his own, was rescued, and survived, and all this while cradling his guts with one hand).
    3. If some of the small intestine has been pulled out and the cut is as described, do the intestines have a "tendency" to try to spill out or is that Hollywood stuff? I.e. would she have to hold them / press them against the cut to keep more from spilling out / if she does let go, e.g. to dig into her first-aid kit, would more of the intestine spill out in the meantime? She has to turn on her side for a while to reach the first-aid kit on her belt.
    4. If she's unable to walk away herself, how long would she survive lying down? So far she's given herself pain relief and "wrapped" the exposed guts in sterile patches, but since she doesn't have medical training either, she doesn't really know how to help herself. Could she just shove the intestines back in, close the cut with sutures, and head to a hospital? Is it possible to use the needle + sutures with just one hand?
    5. What kind of long-term effects would an injury like this have if any? Would her digestive system work normally? How serious is the risk of infections and how dangerous would one be? The floor on which the intestines were pulled isn't sterile, but it's still a floor (a dusty one, though), not the inside of an outhouse.

    Thanks in advance!
     
  2. GingerCoffee
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    GingerCoffee Web Surfer Girl Contributor

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    Yes, think gas pains and appendicitis, both very painful. But just exposed to the air, not stretching or inflamed, it may not cause constant pain. I watched abdominal surgery in school and the surgeon did a lot of poking around looking for the appendix (to check it before closing but it wasn't the reason for the surgery). He commented all that manipulating was going to make the patient sore when they awoke.

    There are two kind of visceral pain receptors, the kind that give you the gnawing aching pain, and the kind that give you sharp pains like the pain when gas distends the bowel.

    See number one.

    Gravity, think spaghetti if you tip the bowl sideways. There are blood vessels and connective tissue that surround the intestines, and the large intestine is more contained in position, but the small intestine is pretty much loosely bunched up in the cavity, except there is connective tissue that loosely connects the gut to the cavity lining, like ribbons.

    You are not taking into consideration you don't just sew the skin back together. To close an abdominal wound like you are describing, first, it would need cleaning, you don't sew a dirty would up. Even if the gut was not pierced, there is still too much contamination from the injury.

    Second, if the bowel were not punctured, and you could clean the wound (I don't think someone could clean it themselves) next you sew the wound shut a layer at a time. You would close the lining of the cavity, then you'd need to approximate the edges of the muscles (also not an easy task, not something you could do yourself.

    All the while you'd need to suture or cauterize any bleeding blood vessels.

    If you want realism, it's not realistic. Better to wrap something (ace wraps, a small sheet, something like that) around the belly holding things together and if you make to a hospital, they'd take you to surgery and fix it properly.

    The prognosis for a person surviving evisceration without surgical repair is close to nil. Infection and sepsis would be devastating without proper surgical repair and antibiotics.

    As for the gut, when you mess with it like that motility stops temporarily. People need NG tubes until bowel sounds return, in a day or so for less disturbance, maybe a couple days for something like you are describing.
     
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  3. T.Trian
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    T.Trian Overly Pompous Bastard Staff Supporter Contributor

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    Thanks a lot for the reply!

    So if she's simply cradling the intestines with her hand or if (while she's digging into her FAK) they are lying on the floor, would it cause constant pain? And would it be more likely to be that constant, gnawing pain or the sharp variant?


    So even if she could hypothetically sew shut the wound herself (wrong, i.e. just on the surface), it would be better if she didn't? Is it better for her to just wrap the exposed intestines in sterile patches (or whatever is used for such a purpose that you might find in a mil-spec first-aid kit) or should she try to stuff the intestines back into the wound and then bandage the wound?

    This isn't really that important since, as the scene stands now, she doesn't even try to sew shut the wound / stuff the intestines back in, but passes out after a second shot of morphine and then is found by people who drag her to a hospital.

    Since the abs were also sliced, would they ever fully recover? How long is the recovery process after an injury like this, assuming she does receive hospital treatment (1. how long would she be bed-ridden, 2. how long until she could walk / move around again, 3. how long until she could run / exercise again)?

    Also, how soon would she need to be hospitalized to survive? Rough estimates would be enough since I'm not going for an 11th hour rescue anyway. My left tricep got almost cut in half, but while its fully recovered now, it did take months. Then again, it was cut vertically, not horizontally, and I'm under the impression that the latter is worse...?


    I'm sorry, I'm really slow this morning or something, but I didn't understand much of that last bit. :oops: Motility = the ability to move? What do NG tubes do and what are bowel sounds?
     
    Last edited: Dec 11, 2013
  4. GingerCoffee
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    Your character has a gaping abdominal wound. It wouldn't be pain free. It would probably be tolerable to touch the intestines if one didn't pinch them or squeeze them hard.

    But what you'd really need is to keep them moist. You could pack sterile dressings in the wound and wait for the bleeding to saturate the dressings, that would keep the gut moist. If there was some sterile saline in the first aid kit you would pack the wound first then pour the liquid onto the dressings. The reason for doing it in that order is because there would be no sterile surface to lay the dressing on before wetting it. Wet dressings act like a wick. If you want to add something clever, have her pack the wound with sterile dressings, then pour the couple ounces of saline eye wash onto the dressings. A lot of first aid kits have a small bottle of sterile saline to irrigate an eye out.


    You don't keep a patient in bed anymore. We used to do that decades ago. Now you get people up as soon as possible, the next day usually even though that sometimes just means sitting on the edge of the bed. A patient with open heart surgery and no major complications goes home in a week.

    Exercise is another matter. You cannot put tension on the sutures for at least a couple weeks with a major repair. The older the person, the longer healing takes. Kids have growth hormone in their systems and that speeds healing. After about 25 you no longer have that advantage.

    This page on wound dehiscence will give you some good background information. It's going to be weeks before your character could attempt heavy lifting or sit ups. Careful gentle movement at first, then gradual increasing exercise would be needed. If you don't use muscles for several weeks, you'd be surprised how quickly they lose tone and exercise tolerance. I had a broken finger in a cast for three weeks. The uninjured finger next to the injured one was also immobilized. When the cast came off the uninjured finger had already developed a contracture that took me a couple weeks to stretch back to normal.


    Motility is peristalsis, the movement of the intestines that propels the contents forward. If your intestines are not moving the contents forward, you have to have a nasogastric (NG) tube to remove the stuff your body keeps dumping into the gut (digestive juices, bile and the gas from bacterial activity). Without the tube you'd be vomiting every couple hours.
     
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  5. Cogito
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    Cogito Former Mod, Retired Supporter Contributor

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    Also, peritonitis is very likely. It only takes a relatively small perforation of the colon to end up with a highly septic abdominal cavity.
     
  6. GingerCoffee
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    ;)

    You don't need bacteria from bowel contents to get peritonitis. You just need bacteria. Something as simple as staphylococcus on the skin can become a pathogen when it runs free in a normally sterile body cavity.
     
  7. T.Trian
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    T.Trian Overly Pompous Bastard Staff Supporter Contributor

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    That's actually a great idea, thanks a bunch!


    Yeah, I remember it took a month or two before my arm was, well, not back to normal, but at least I could do two-handed exercises like push-ups, pull-ups, the bench etc. Luckily the character has a about a couple of months or a little less to recuperate before the story takes her back to combat.


    Approximately how soon would the vomiting start from receiving the injury if she doesn't get an NG tube?
     
  8. GingerCoffee
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    Hard to say and it probably varies. I had a patient once dying of cancer whose intestines were blocked but he chose to vomit rather than have the NG tube. He vomited one or more times a shift (8 hours) if I recall correctly (it was a very long time ago).
     
  9. T.Trian
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    T.Trian Overly Pompous Bastard Staff Supporter Contributor

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    I think I'm starting to get a grasp on how to write the scene. Thanks a bunch! :)
     

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