So, appendectomies. Let's say a group of medically trained individuals are in some kind of dystopic or post-apocalyptic scenario, and a civilian has appendicitis. Could they possibly save them? Like, if they had all of the knowledge but limited tools, could they keep the patient from getting a terrible infection? What would they HAVE to have to succeed? Would it be completely implausible to write an appendectomy (or any invasive surgery, for that matter) into such a complicated environment?
So immediately when I read this I
thought of a scene in the novel Alas,
Babylon where a rural family doctor has to perform an appendectomy on a
young boy after his medical supplies are looted in a wake of a nuclear
apocalypse. It’s an older book, but if you like post apocalypse fiction, it’s
a classic and very whumpy.
Moving on, though.
The appendix is a hollow, worm-shaped structure attached to the junction of the small and large
intestines. As far as we know, it acts as a reservoir for the good kinds of
gut bacteria, and drains into that junction between the intestines.
Appendicitis occurs when the
opening of the appendix gets blocked. Unable to drain, a buildup of bacteria,
white blood cells and mucous increases pressure in the hollow part of the
appendix and causes inflammation. When pressure in the appendix gets higher
than the pressure in the surrounding blood vessels, it cuts off the flow of
blood to the appendix, which begins to die. This is a bad thing, because a
dead appendix can no longer contain the gooey, bacteria-mucous-white blood
cell mixture and can tear. If it tears, even these good bacteria can cause
infection and inflammation outside of the digestive tract and this can lead
to a lot of suffering and sometimes death.
This whole process is usually
very, very painful.
And while there are other options
in limited circumstances, surgery is often the best choice for treating
appendicitis.
An appendectomy involves the
following steps:
Making an incision in the skin
Ripping the muscle (it heals
better ripped than if it was cut, promise)
Opening the peritoneum
Pulling out a part of the
intestine called the cecum, the
junction where the appendix is attached
Now, surgery is routinely performed in low-resource areas of the
world. Areas
where oxygen, electricity, and even water supply, not to mention equipment
and access to sterile instruments, may be unreliable or very limited. Some
studies estimate that surgery-related death occurs at rates of 5-10% in these
areas (compared to 0.4-0.8% in areas with reliable water, power, oxygen and
basic equipment/sterilization resources). So going forward be prepared that that may be a risk depending on your characters’ circumstances.
Being that this is a pretty
intensive and delicate surgery that can take up to an hour to complete, and guessing you’re looking at a locale with unreliable water, power and oxygen, here’s what you would need, at absolute minimum:
A clean, well-lit location in which
to work
Some form of general anesthetic
that can last an hour or more (It can be nitrous oxide or chloroform (know
risks and side effects of each before writing), but is non-negotiable)
Skin antiseptic
Something to sterilize
instruments (at minimum, the ability to boil something for 10 minutes)
A sterilizable tray on which to
put sterile instruments (this can be a small cookie sheet as long as its been
boiled)
A sterile or
sterilizable scalpel or razor blade to cut skin and peritoneum
Sterilized, unwaxed and
unflavored dental floss (for use as suture material)
Sterilized, curved suture needle
Sterilized hemostat or other
pincer/tweezer tool
Sterile gloves, or at the very, very least clean (the kind that come
in the box) gloves disinfected with skin disinfectant
Someone to monitor vital signs
(thermometer and blood pressure cuff strongly recommended, pulse and
respirations can be taken without equipment).
Someone to perform the operation
Someone to assist
The favor of your chosen deity
Whoever was performing the
operation would follow the same basic flow as the video above, even in a
low-resource environment. The same would go for any routine surgery.
Antibiotics should always be used if available, though one high dose before the
surgery should be enough to decrease risk of infection, especially if supply is
very limited.
Remember above when I said in limited circumstances other treatment options could be used? One is basically just waiting it out. In WWII, US sailors onboard submarines couldn’t get medical attention for weeks at a time. Of those who developed appendicitis, only about 10-15% died. Statistically, this is about 1.5-2 times as risky as performing the surgery, but it is an option for your narrative.
To fully answer your question- it would be possible, but risky, to perform surgery on someone in a low-resource environment.
Hello! I've got a question, if you wouldn't mind? I'm wondering how people would treat the insides of a stab wound type thing. Specifically, a character who's been stabbed right through with a piece of like twisted metal, about the size of kid's arm? Which sounds creepy but okay. So he's been stabbed with it (on his left side a little bit below the bottom of his ribs) and I don't really know what to do once the thing's out of him, as in, what to do with the inside of the hole it left? Thank you!
Warning, some pictures in this post contain
blood, wounds and clinical gore. Reader discretion is advised.
Picture a large cube of
gelatin. Now stab it with something and take that something out. Hole kinda
closes in on itself, right? That’s because nothing was removed, just moved out of the way. After a few seconds you can’t see it on the surface.
Humans are a little like that too- assuming the injury was low velocity and
didn’t actually remove tissue from the body (ie- not a gunshot or shrapnel
wound), the tissue closes up and there’s not really a hole beyond the entrance
and/or exit wounds.
This is a picture of a
stab entrance wound from a knife. Notice that the skin is parted, but while the
wound presumably goes much deeper, nothing below the fat can be seen.
The thing is, visible or not, there was a lot of damage done
there. Large blood vessels may
have been severed, vital organs and muscles that control breathing may have
been injured. If either of these happened, there is a good chance the patient
would bleed out, get a deadly infection, or suffocate before they healed
naturally.
In the past, the only practical way to prevent these outcomes
was to perform an exploratory surgery called a laparotomy. Ever watched M*A*S*H? That’s pretty much the surgery the characters
are performing whenever they’re in the operating room.
Think of the abdomen as a sack of different components, all
needing different procedures to restore them to working order. A laparotomy is a catchall name for this group of procedures. In a laparotomy, a surgeon makes a separate
incision, usually down the middle front of the patient, then searches for injured
organs and tissues and repairs as much damage as possible from the initial
wound. Here is a video of a laparotomy used in a multiple stab wound trauma
situation.
Goals of laparotomy
include:
Control of bleeding
Identification of injuries
Control of contamination
Reconstruction
Pic of open laparotomy:
Pic of sutured/stapled
laparotomy incision:
Pic of laparotomy scar:
Pic of wound dressing for a laparotomy:
Today, imaging equipment like CT scanners mean a laparotomy only
needs to be performed if there is definitely something to fix (in the video, the surgeon fixes damage to the patient’s liver,
diaphragm and other organs after seeing injuries to them on the CT scan). Or if
the patient is showing immediate signs of distress:
Severe bruising, unstable
blood pressure or a “crackling” feeling when pressing on the patient’s abdomen-
meaning the patient is experiencing life-threatening internal bleeding.
Difficulty breathing that
persists after draining of a hemo- or pneumothorax- indicating damage to the
diaphragm, possibly more internal bleeding as well.
Ridged, painful abdomen-
indicating peritonitis from bowel contents spilling into the peritoneum (sterile part of the gut).
If there is no reason to
need a laparotomy (little or nothing problematic shows up on the CT and the
patient is stable), the entry wound is cleaned and dressed, and the patient is
given antibiotics to prevent infection. Depending on how bad the wound was, the
patient may be admitted to the hospital for additional care or observation, or
discharged directly from the emergency room.
In the case of your character, he will definitely need a
laparotomy. The metal likely pushed
tissue out of its way more than it cut chunks of it out, but being that it was
a twisted piece of metal, there was plenty of opportunity for tissue to get
ripped or snagged on it. Once the metal is removed, that damage all still needs
to be recognized and repaired.
In the part of the body you’re talking about, I’d be most
worried about the large and small intestine, but there is a chance the metal
snagged the diaphragm as well, or even the kidney depending on its trajectory. Any damage to the diaphragm will be repaired by sealing or
artificially patching any holes with the goal to return it to its original,
airtight state.
If any of the intestine is torn, you’re looking at a very high
risk for peritonitis- the inflammation of the
sterile sac your organs are housed in due to acid, bacteria and other foreign
substances that could spill out of the intestine. This can be very dangerous or
even deadly, so it is important to close any leaks, find any leftover bits of
metal so they can’t cause further harm, and wash the peritoneum during the
laparotomy to prevent this.
Kidneys have a lot of blood vessels in them. If injured, they bleed a lot, possibly life threateningly. Often,
if the damage is minimal, the bleeding can be stopped during the laparotomy and
special sutures used for very delicate tissue can repair the damage. If the
your character is unstable and losing way too much blood, however, the fastest
way to stop the bleeding is to remove the entire kidney.
TL;DR Your character’s abdomen is basically a sac of different
organs, each with their own needs, so its less about the “inside” of the wound
and more about what was damaged and needs fixing. After removing the piece of metal, the surgeon would make a
different incision in order to access those organs, find damage, and repair it
before closing everything up.
So much of the book feels like Crowley just desperately wanting to be around Aziraphale, though this fact is generally only hinted. He’s the one that seems to organize all their meetings. He approaches first. He puts the plans in motion. He invites Aziraphale to go places with him. It never seems to be the other way around, except for near the end when Aziraphale discovers in Agnes Nutter’s book that the antichrist is in Tadfield and he suddenly thinks to call Crowley.
Of course, they do spend time together in Aziraphale’s bookshop rather than in Crowley’s flat, but upon further investigation, that was probably because Crowley followed him home. There’s one specific part in the book that really made this all hit me. Aziraphale is in Madame Tracy, and he’s trying to talk Shadwell into killing the antichrist, and Shadwell asked if it would be at all similar to getting rid of a demon (Shadwell at this point thinks Aziraphale is a demon since he walked in on him doing what looked to be some Satanic ritual, and after waking up has suddenly been presented with Madame Tracy possessed by the “Southern Pansy,” so he’s got demons on the brain), and Aziraphale reflects on the fact that the way he gets rid of demons (namely Crowley) is by acting as though he has something much more important to be dealing with, and that Crowley “usually gets the message,” and leaves–implying that Crowley often comes calling on Aziraphale, and Aziraphale usually has to make him leave once he’s grown tired of his presence.
I guess what I’m trying to say is that Crowley seems to be the one desperately, unashamedly in love, the one who wants so much to be close to the other, and Aziraphale, though it’s clear he has feelings for his acquaintance of 6,000+ years, either doesn’t feel as strongly as Crowley does, or he does and just lets the whole “angels and demons shouldn’t be friends” thing get really in the way. That or, possibly (and this is the option I prefer), he just does not know how to express his desire to be closer to Crowley until he really needs him. Certainly if he really did not want to be around Crowley at all, he would keep his distance and maybe even make it so that Crowley couldn’t find him no matter how hard he tried. Certainly he’s powerful enough to do that if he wanted to. Instead he accepts the invitations, he goes along with Crowley’s idiot plans, he allows the demon into his home, and he gets in his car (a very dangerous thing to do, and yet he does it willingly when neither of them likely even have need for such a mode of transportation), doing the minimal amount to keep the man who should be his “hereditary enemy” close at hand, because in the end, he really does like him.
And I think that’s why the series looks like it’s going to present their relationship so much “differently.” It’s only different on the surface, because you’d have to really read into their interactions to see that Crowley’s trailing after him rather than them mutually keeping up with one another. Aziraphale does want to be close to Crowley, but he’s never the first one to reach out because he can’t let heaven see an angel who willingly fraternizes with demons, and he also isn’t sure himself whether or not it’s truly okay. The book reflects, if minimally, this very idea, which seems to be coming to life in the series so far as I can tell from the trailers and the behind the scenes promo video.
this entire setup? allows aziraphale to remain in his Denial Comfort Zone and not have to examine his own reliance on crowley. he can act like having crowley around is an imposition and also know that crowley isn’t going to leave, although i think the issue is less what anyone else thinks of him and more his ability to lie to himself about who he is?
crowley is definitely the one putting in the emotional legwork throughout the book, he’s more considerate of aziraphale’s feelings than aziraphale is of his, and it’s likely (i think) the biggest reason they end up so close is because crowley is persistently friendly and still knows when to back off
Thank you for all the work you put into providing us with Good Omens content! I'm always so impressed by how you find new trivia or interviews or promo material so quickly, and make tons of great gifs from teasers and trailers. Also you're a huge sweetheart ♡ Keep being awesome!
Awwww, thank you so much!
I just woke up, am still in my pyjamas (had to check tumblr first because priorities) and this made my day! (also might be blushing a little bit but shhhh)
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