Submitted by Dr. Mohan on 04 August, 2011
It was during my training period. I was on duty that day. The year was 1990. I was already at the emergency department of the hospital in Chandigarh seeing a patient when there was a commotion and panic [more than usual I might add] and in came a patient whose face looked more like a watermelon used for a target practice. He was drowning in his own blood and the face was kind of opened out from the middle like a book, there was no structure. Agreed, he needed an emergency physician pronto but as he was obstructing my instinct and training took over and I proceeded to do a tracheostomy right there on the bed under local anesthetic [tracheostomy is a process of making a small opening in the lower part of neck to gain direct access to the windpipe in a person whose airway is blocked from above]. It was important to secure his airway and make him breathe, everything else can wait. As soon as we had secured his airway, he was sedated and the split face was kind of closed with a lot of packing inserted in the nasal passage, throat and wherever needed. His face was bandaged like a mummy’s face to stop the bleed. Then we completed his evaluation and it was learnt that this was a as result of a suicidal attempt he was a policeman who put his 303 Rifle under the chin fired. The bullet had burst open his face and exited via the forehead without injuring the brain.
Closer examination revealed that his eyes were intact and there was actually no skin loss either. He was taken up for surgery immediately and over a 7 hour period working through the night, I fixed all his fractured bones, managed to repair as much of the lining mucosa as I could but brought the muscles and skin together only by a few stitches tied loosely. We tried to use minimum hardware, a lot or work was done by interosseous wiring. A lot of swelling was expected and did occur but that passed. Skin was closed later. I was delighted to see that all my work healed without infection and in a month or so he was none the worse for all this trauma, he had of course a long vertical scar in the middle of his face. He underwent psychiatric treatment, counseling and was back to his job. He thanked us profusely of course but I cannot forget the look of perpetual wonder on the face of his colleagues who brought him into the emergency. I think I gained some respect as well among my peers.
This case illustrates once again the need for plastic surgeons to have all round training to be able to deal with surgical emergencies when called upon to do so. We all should be doctors first, surgeons next and then plastic surgeons. Although it should be obvious, this needs to be stated in today’s world where junior trainees considering a career in plastic surgery are in a hurry to become cosmetic surgeons straightaway; I think this is a dangerous trend. The public is always better off with a PS who also has had a good general surgical training. This case also illustrated the value of early stable bone fixation but delayed soft tissue closure in such injuries. But put simply, even after all these years I do not cease to wonder at the power of plastic surgical principles in tackling difficult problems.