Impaled Objects: Why They Are Left In Until Surgery

Why pulling it out is dangerous

While the object stays where it is, bleeding is limited to what can leak around it. Pulled out anywhere other than theatre, it leaves an open hole in a vessel that nobody can see or reach. In the upper neck, between the angle of the jaw and the base of the skull, the carotid artery and jugular vein run close by, there is no room to press on a bleeding vessel, and the jaw sits in the surgeon's way.

In theatre the surgeons can open the space first and see the whole length of the object and the vessels next to it. When a branch that had gone into a man's face below the jaw was finally taken out this way, two arteries it had torn were tied off, and the carotid and jugular turned out to be undamaged.

Shown in MC-036: They cut the branch down. Nobody pulled it out.

Why it may be shortened, or cut free, but not pulled

The branch in that case was about eight feet long. Eight feet of wood cannot travel in an ambulance or fit on a trolley, and every movement of the free end is passed, like a lever, to whatever the other end is lodged against. The first hospital cut it down to about two feet and sent him on with the rest still in place.

Pulling can also make things worse in a more direct way. A hand drawn into a meat grinder is gripped by the angled flights of the screw, so pulling backwards wedges it tighter. When the screw would not turn back, the machine was cut off around the hand by a welder, in theatre, under general anaesthetic.

Long, brittle objects are treated the same way at the removal stage. A bamboo stick that ran from a man's eye socket to the back of his throat was cut and taken out in controlled pieces rather than dragged back along its path, because pulling risks snapping it and leaving fragments in tissue nobody can see.

Shown in MC-026: The hand arrived still inside the machine · also MC-006 and MC-036

When the patient cannot lie flat

The usual way to secure an airway is to lay the patient flat and pass a tube through the mouth. Some injuries rule that out. A man whose face had struck a steering wheel kept his airway open only by sitting forward: the broken midface hung away from his throat, and lying flat would have let it fall back and close it. He was talking and his oxygen saturation was 99%, and neither predicted what would happen if he were laid down.

In both of these patients the airway was made below the damage, through the front of the neck, rather than passed through it. The man with the branch could not lie on his back because the wood was lodged behind his neck, so he was turned onto his side and the opening was made under sedation and local anaesthetic, with a general anaesthetic given only once the tube was in.

Shown in MC-031: He could breathe sitting up, but not lying down · also MC-036

Why wood is hard to see on a scan

Metal and glass are straightforward to find on imaging. Dry wood is very low in density, so on CT it can look like air, fat or muscle, and a tract of wood can be reported, reasonably, as trapped gas. That is what happened to the bamboo stick: it stayed in for five more days.

Wood also splinters and carries organisms, so a fragment left behind tends to show itself later as an infection that will not settle. In that case the persistent discharge from the eye was the clue, and reconstructions of the scan in several planes showed the whole object.

Shown in MC-006: Wooden foreign body on CT: the scan said gas

The cases

1. 10 daysfrom impalement to homeMC-036EmergencyThey cut the branch down. Nobody pulled it out.A road accident drove a branch through the side of his face and out of his mouth. It was cut from eight feet to two, left in place, and removed only once the vessels around it could be controlled.
2. 0 hmachine still attachedMC-026EmergencyThe hand arrived still inside the machineA welder freed him in theatre. The amputation was decided by something much simpler than the damage.
3. on arrivalsitting forward to breatheMC-031EmergencyHe could breathe sitting up, but not lying downHis face hit the steering wheel and the midface came away from the skull. The position he was holding on arrival was the finding that mattered most.
4. 5 daysbefore anyone looked againMC-006DiagnosisWooden foreign body on CT: the scan said gasWood reads as air on a scan. The clue that overturned the report was an infection that would not settle.