Posted by Dr. Aditya Sharma, MD
A fifteen year old boy was climbing a tree near his house to collect guava fruit when he lost his balance and feel out of the tree. He wasn’t very high in the tree, but was impaled on one of the branches near the bottom. The wound wasn’t very deep, and he got up without much concern or pain, until he noticed a hole in his abdomen with his intestines hanging out. He walked home and showed the wound to his family, who promptly put him on a bus for two hour trip to our clinic.
Dr. Jhapat and I were at the staff quarters at 7 pm when we received word from our in-clinic nurse midwife over walkie talkie that a boy had arrived with his intestines hanging out. We immediately went down to evaluate. The boy was sitting outside our clinic, appearing fairly comfortable, with his family next to him. His shirt covered his wound. We brought him into our treatment room and examined him. The “intestines hanging out” turned out to be a long strip of omentum (lining the outside of intestines) the that had delivered through a hole in his abdomen caused by the fall.
The boy came in with his "intestines hanging out"
Dr. Jhapat and I discussed the best course of action. The boy had no signs infections of an abdominal infection, and an emergency ultrasound exam was normal. It didn’t appear that there was any injury to his internal organs. We decided to close the wound, provide antibiotics to prevent infection, observe the patient, and refer immediately to a surgical center at the first signs of danger.
After applying a liberal amount of local anesthetic, Dr, Jhapat extended the margins of the wound to look more carefully. No foreign bodies were present, and the wound tract turned out to be far from perpendicular to the surface of the abdomen. After some exploration, however, we found the edges of the deep fascia. As we were about begin repairing the fascia, our battery system, which had been operating continuously for two consecutive days since the electric grid had been down, ran out of electricity. Our backup generator was being repaired. As such, we were in complete darkness. Our midwife held a flashlight between us, and we successfully closed all layers of the wound. We prescribed him intravenous metronidazole and ceftriaxone (two powerful antibiotics) to cover possible infection, provided lactated ringer’s (an intravenous fluid solution) to maintain his fluid status, and prescribed regular diclofenac (a drug like Aspirin) for pain control. Dr. Jhapat and I returned to the staff quarters feeling confident that the patient would do well over night.
In the morning, twelve hours after the procedure, he had already passed urine and had excellent bowel sounds. This indicated to us that those essential functions had survived the impalement. We discharged him after three days, once after he had started eating and moving his bowels. We kept him on IV injections of metronidazole and ceftriaxone for a full seven days, for which he appeared dutifully to the clinic every day. On day ten after his presentation, he returned to the clinic for us to remove his stitches. Our staff was proud that we could manage such a complex problem in our remote site, and the patient and his family were quite pleased that they did not have to travel to India or elsewhere to get essential medical care. This was definitely a huge victory for someone who narrowly escaped significant injury.
