The Case of the Wounded Woodsman and His Dedicated Physician

Albert B. Lowenfels, MD

Disclosures

September 02, 2009

How Would the Patient's Wound Be Treated Today?

St. Martin sustained the full force of a shotgun blast fired accidentally at close range, resulting in a complex wound involving the left lung, the stomach, and the diaphragm. Beaumont describes a "fist-sized" hole (approximately 9 x 9 cm) in the left lateral chest wall. St. Martin apparently remained hemodynamically stable after his injury, although the sphygmomanometer wasn't invented for several more decades -- so there were no blood pressure measurements.

Figure 3.

Beaumont's sketch of St. Martin's wound about 4-6 weeks after the injury.
From Beaumont W.5

Even today, this injury would present a significant challenge to a surgeon.[6,7] However, long-term results following current surgical repair of severe chest wall injuries are excellent, with patient status being similar to the general population.[8] Current management would include the following:

  • Careful physical examination supplemented by imaging studies to determine the extent of injury.

  • If there were a pneumothorax or respiratory compromise following this chest wound, ventilatory support would be provided via an endotracheal tube until the patient was ready for surgery. (Note: there was no mention of shortness of breath from a pneumothorax in St. Martin's case.)

  • Exploration via a left thoracoabdominal incision.

  • Careful exploration to ensure that no other organs, such as the pancreas or the spleen, had been injured.

  • Debridement and cleansing of the original wound to remove shattered rib fragments, necrotic lung tissue, imbedded clothing, fragments of the shell, and food particles.

  • Blood transfusion, rather than bloodletting, as was done for St. Martin.

  • Closure of the gastric wound and the diaphragmatic tear.

  • Repair of the chest wall defect. This would probably require application of a synthetic mesh covered by a muscle flap. If necessary, the repair in the chest wall could be closed with a split-thickness skin graft.

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