BookPost Supplement

The gulf between good published writers and bad published writers is wide, but that between writers who research well and seriously, and then use that research wisely, and writers who are too lazy to research, and who use what little knowledge they have carelessly, is even wider.

We have named Diana Gabaldon as one whose dedication to authenticity we can admire without reservation. Yes, okay, she admits she hasn't actually, herself, been timewarped from a Scottish stone circle back into the Jacobite conflict of the 18th century (not yet, anyway), but in her quest to establish the historical accuracy of what she writes about that period she has explored almost everything else.

Naturally, as do now so many successful authors, she exploits the Internet's resources with zest, using both the Web and relevant bulletin boards. And she receives a lot of help from the friendships she has formed online. We quote here an example, and do so for two reasons. The first is to illustrate the depth of research undertaken by good writers (and this really is a good sample of Diana's operational method). The second is to illustrate the kindliness and expertise the Internetters make so readily available.

So, from Ellen Mandell's post to the Writers' Forum on CompuServe, here is ~

A Layman's Guide to Emergency Tracheostomy

A sudden jerk that doesn't crack the C-spine, snap the spinal cord, or dislocate the cervical ver-er-te-bree-ee can still cause extensive soft tissue injuries of the neck and throat. The object so sublime is the resulting edema, which may take 12 to 24 hours to develop. This can cause a critical airway obstruction and occasion the need for an emergency tracheostomy. (Besides singing this bit, I'm making a distinction between -otomy and -ostomy; in the latter, a stoma is kept open by picking up the margins of the tracheal incision with hooks and tacking the wound edges to the skin with a few sutures.)

This not only fits the botched hanging and your imagery very well, it forces Claire to make a horribly difficult clinical decision and provides the possibility of a complete recovery ~ barring the scars and the slow resolution of mental and physical post-traumatic symptoms like neck pain, limited neck and shoulder girdle mobility, dizziness, headaches, dysphagia, and nightmares. Also, from a novelistic perspective, a tracheostomy calls for someone to hold Roger's life in steady hands and watch while Claire slits his throat.

There is serious risk in moving Roger's head and neck; the sharp edge of a fracture could severe the spinal cord; a vertebral dislocation could compress the cord irreversibly. But the watcher must overextend Roger's neck and keep it from rotating, precisely countering the forceful, yet delicate, tugs of a skilled surgeon.

Overextending the neck pulls the trachea cephalad out of the mediastinum, displaces it forward, and tenses the skin and facsia. Straightening the neck lines up the trachea between the jugular notch of the sternum and the superior notch of the thyroid cartilage. That makes the trachea easier to identify and centers it between the great vessels on either side.

Any rotation of the head and neck leads to displacement of the trachea, and this has caused fatal errors. There are case reports of emergency operations where surgeons have lacerated a common carotid artery or internal jugular vein, or missed the trachea completely.

With a low tracheostomy, the procedure I think Claire would choose, there is grave risk of intractable hemorrhage from communicating branches of the anterior jugular veins and the midline vessels supplying the thyroid gland. (The thyroid gland isthmus lies in front of the second, third, and sometimes the fourth tracheal cartilages, which is where the trachea is vertically incised, so the thyroid must either be mobilized headwards ~ if the isthmus is loosely adherent to the pretracheal fascia, this can sometimes be done with blunt dissection by the fingers ~ or the isthmus must be clamped, divided, and ligated.)

There is also a risk of stabbing through the posterior membranous portion of the trachea and perforating the esophagus; the tracheal cartilages are U-shaped, not complete rings like the cricoid, and a tracheo-esophageal fistula would no doubt have been fatal in the eighteenth century.

Claire might do a cricothrotomy first; it's quicker, easier, and safer. Since you know the anatomy, I expect you could do one in an emergency; popping a small sharp tool through the cricothroid ligament and turning it ninety degrees takes little more than brass balls. But a cricothyrotomy might not relieve Roger's obstruction, would be hard for Claire to keep open, and can lead to a scarred and constricted airway ~ subglottic stenosis. Besides, it wouldn't require a watchful assistant.

If Roger survives operation and regains consciousness quickly enough that he doesn't succumb to dehydration ~ I suppose Claire could try tube feeding or an IV ~ his wound may heal spontaneously. (If it doesn't get infected and he doesn't die first from pneumonia, that is. ) When the swelling lessens and he's clearly on the mend, the silk sutures that were used to loosely tack the tracheal stoma to the skin can be snipped, allowing the wound to heal by secondary intention. The skin must never be sutured tightly around the trachea, so that escaping air doesn't dissect into the mediastinum where it might embarrass circulation or rupture into the pleural sac and collapse lungs. Until the mucosa seals and the edges granulate in, all that's needful is to keep the wound clean and lightly covered.

Finally, I can't resist observing that a doctor who actually thinks her primary obligation is "do no harm" wouldn't operate on a suffocating patient with a bloody mess of a (possibly broken) neck under field conditions. And we wouldn't do it bare-handed, either.


The editorial staff of The Baronage Press, all professional scribblers, hereby nominate Ellen Mandell as a candidate for the 1998 Internet Samaritans Award (an award that recognises the Internet for what it is ~ not servers and not telephones and not PCs, but people).


DRUMS OF AUTUMN by Diana Gabaldon was the second of the recommendations in this month's BookPost. Her name is, of course, very well known, for this is the fourth volume of her series about Claire, a time-travelling bigamist whose loves are shared by Diana's readers. ("Drums of Autumn" by Diana Gabaldon is published by Arrow Books ~ ISBN-0-09-966431-3 and is HIGHLY RECOMMENDED.)

You may order DRUMS OF AUTUMN now!

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