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14:09:43 |
Adm. to 2/5 A.G.H. |
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Gen. cond. fair: in spica. Soon after adm. asked for bed pan. Began to haemorrhage freely, & blood poured over top of spica and from perineal part. Rapidly became semi conscious and shocked from blood loss.
Morphia given statim. Immediate transfusion begun - 1st litre run in in 20 minutes. Then taken to theatre.
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(18th day) |
Opn : Pentothal:
Spica removed - vast amt. of clot - wound offensive.
Much necrotic tissue. TWO spurting arteries (? branches profunda femoris) ligated by haemostatic suture.
Some metallic F. bd and necrotic bone removed -
gross comminution subtrochantiric region of femur.
Vac.gauze & sulph. pulv. Fixed extension on Thomas splint. |
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15:09:43 |
Transfusion continued until 4 litres had been run in in 12 hrs. Gen.cond. this a.m. excellent. Splint comfortable. No oozing. No reaction from transfusion. |
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1500 hrs:, |
Oozing recommenced: bright blood. Packs placed over wound and tight bandage applied. |
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1800 hrs:, |
Gen. cond. quite good. No further bleeding. T. 1012 |
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2300 hrs: |
Very slight ooze thru-dressing - odour offensive. |
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H.B.=13.5 gr % |
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16:09:43 |
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0830 hrs |
Haemorrhage recommenced in considerable quantity - bright red - condition going off. Blood transfusion recommenced and taken to theatre.
Opn: Pentothal - dressing taken down, pack removed. Immediate brisk bleeding from large artery - probably profunda femoris. Could not be secured with haemastate - wound packed hard. Gen. cond. grave from blood loss. Pack left in situ and transfusion continued throughout day.
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1900 hrs |
Gen cond. much better. In consultation with O.C. Surgical decision to amputate because of gross infection - extent of vasc. damages and gen. cond. of patient which would not stand further blood loss. |
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2030 hrs |
Opn: Pentothal |
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Splint removed.
Amputation L. thigh with post skin flap.
Femoral vessels isolated and doubly ligated. Muscle cut through & vessels clamped seriatum; bone divided through fracture site - considered condition would not stand disarticulation.
Sulph pulv, vas gauze, firm pad.
Cond. during opn. became very grave, but improved soon after. |
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2300 hrs: |
Colour good. P. 112. T. 1004
Pulse volume fair and improving.
Transfusion continuing Third litre begun.
Taking fluids well by mouth. |
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2359 hrs: |
Some oozing thru dressing. Pulse steady. |
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17:09:43 |
Gen. cond. much improved. Transfusion suspended 0900 hrs. Has had 12 litres of blood, since evening of 14:09:43, (ie 60 hrs) T. 103°Passed 112 oz urine in 11 hrs. |
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19:09:43 |
No h'age - offensive discharge thru dressing. |
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20:09:43 |
Stump redressed - necrotic tissue and slough near bone - peripheral muscles and skin healthy: gen. cond. slightly better. |
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22:09:43 |
Culture from Wd.on 16:09:43 |
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Growth of proteus vulgaris, Ps. Pyocyaneus and a few colonies of haemolytic strept.
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Cl welchii N.
Any sporing,
anaerobes |
Not obtained. |
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24:09:43 |
High chrst persists. Gen. cond. improved.
Wnd.redressed. still very dirty pus had collected beneath post flap over lower part of buttock.
- cavity irrigated with H2O2 & saline & redressed.
Culture from Wd: |
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B.C.C. 1 Proteus vulgaris, & a haemolytic staphylococcus. |
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27:09:43 |
R.BC |
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2,300,000 cu.mm. |
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HB |
: |
8 G m % (N = 14.5 G) |
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W.BC |
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1800 |
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N |
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75% Left shift in ventrophils |
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E |
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2% |
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B. |
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1% |
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L. |
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18% |
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M. |
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4% |
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Wd redressed: Stump much cleaner and granulating - bone end jagged and nicrotic - some pus collecting beneath post flap over buttock. Syringed with H202 and saline. One spurting artery under sewn.
Gen.cond. fair - but profound waxy pallor. |
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28:09:43 |
Had 2 litres blood transfusion - much better to-day. |
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30:09:43 |
Stump redressed - granulating well - less draining from pocket under flap. To lie prone as long as possible each day. |
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1:10:43 |
Mod. haemorrhage c700 hrs - stopped with pressure and morph. gr. 1/4. Gen. cond. not disturbed. |
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1100 hrs |
Brisk profuse secondary h'age with rapid deterioration in condition to stage of profound shock with sweating, impalpable pulse, air hunger & semi consciousness,
Blood transfusion statim: three (3) litres given by 1700 hrs. Gen. cond. very good.
HB = 14.2 G ,(N=14.5 G) |
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02:10:43 |
Good night. T. normal. Bandages loosened & reapplied. Dressing NOT disturbed. |
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04:10:43 |
Gen. cond. very good. Slight bleeding thru dressing. Dressing taken down. No bleeding point seen - Some greenish, yellow slough overlies stumps of femoral vessels. Much less pus from pocket under post flap. Wound redressed. |
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05:10:43
0900 hrs |
Free secondary haemorrhage recommenced after a spasm of coughing - pressure pads and bandages applied, but considerable blood loss & condition became grave.
Blood transfusion begun |
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1400 hrs |
Three (3) litres blood given. Continuous manual pressure maintained. H'age? from femoral - may need ligature of ext. iliac artery. |
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1700 hrs |
Manual pressure over femoral vessles maintained for 7 hrs.
5th litre blood begun - gen. cond. much improved. |
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2330 hrs |
6th litre begun. No further bleeding. Passing small frequent amts of urine. |
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06:10:43
0900 hrs |
7th litre blood begun. Taken to theatre: dressings removed.
Catheterised - oz LX withdrawn. |
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1000 hrs |
Opn- I.V. Pentothal: L. lower paramedian incision.
Ligation ext. iliac vessels:
The B.Vs were approached thru fascia transversalis & exposed extra peritoneally. The perivascular sheath appeared oedematous & friable - the vessels were isolated - when hernia needle with ligature had been passed around artery, the vein split along its length & there was considerable blood loss - controlled by digital pressure for several minutes: Patient's condition became extremely grave: blood transfusion continued: blood mopped from wound - large haemostats clamped on vessels and three ligatures put on artery, two on vein and one around both - complete haemostasis obtained - wound closed -stump redressed - quick incision made in post flap.
Cond. at end of opn very poor - resps periodic with long intervals of apnoca - given oxygen and artificial respiration - Cond. slowly improved: left in theatre all day. |
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1930 hrs |
Returned to Ward. Gen. cond. quite good. Catheterized - oz XX Acid -clear S.G. - 1005 |
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07:10:43 |
Had good night. T. 98° P. 112 R 24 |
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1100 hrs |
Catheterized oz xxx. Had 8 litres of blood & 1 of serum, since morning of 5:10:43
Total blood given since admission 14:09:43 = 25 litres |
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09:10:43 , |
Cough troublesome & rather depressed last two days - mod. jaundice in pallor - no more oozing. Temp. still elevated. |
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10:10:43 |
Looks & feels well: wd dressed as discharge offensive & free.
Hb = 13.2 |
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11:10:43 |
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0900 hrs |
Some oozing thru dressings - pressure pads and bandage - gen. cond. o.k. |
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1100 hrs: |
Free haemorrhage - dressings removed - caused bleeding from vessels just lateral to femorals (? back bleeding from superficial ext. iliac artery) easily controlled with pressure. Fairly considerable blood loss - cond. went off. Given 2 litres fresh blood from 4 compatible donors during afternoon - colour much improved - no further bleeding. |
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1930 hrs |
T. 106 Abdomen a little distended - crepitation in tissues - L. ant. abdom wall & L loin ? gas. PR -144 R.36
Tepid sponge. T.1024 in axilla. Catheterized oz X |
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12:10:43 |
Had very good night. Eating and drinking well. T.P.R. normal. Wd redressed. Thick brownish offensive pus under post flap.
Wound culture: Growth of proteus vulgaris & an anaerobic strept. |
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14:10:43 |
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0545 hrs |
Some bleeding thru dressing - bright red - stopped with pressure over femoral vessels with pads and extra bandages: cond. has not deteriorated. |
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2420 hrs |
Onset bright bleeding after spasm of coughing. dressing taken down. O.E.Slough 1" diam at root of femoral vessels - bleeding freely from this site - strong arterial pulsation visible and palpable in femoral canal easily controlled by digital pressure.
Pressure pad of rolled bandage firmly bound over femoral canal. For ligature in theatre in a.m. |
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15:10:43 |
Hb = 11.2 Gms % (N= 14.5 G) |
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0900 hrs |
No further bleeding. |
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18:10:43 |
Hb =_10.5
Stump redressed : no bleeding - pulsating slough over femoral canal free discharge of pus from under post flap. |
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20:10:43
0100 hrs |
Free haemorrhage from region femoral canal.
Fresh blood transfusion had been started 1700 hrs 19:10:43 - almost completed 2 litres when h'age commenced.
Bleeding stopped with pressure. |
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21:10:43, |
Hb = 13,5 Gms % (N =14.5) |
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22:10:43 |
Stump redressed: when dressings removed, powerful spurt of blood from slough infemoral canal - stream rose 2 feet - easily stopped by digital pressure while pressure pad applied. Pressure sore over R. iliac crest - deep & very tender. |
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24:10:43 |
Moderate bleeding recurred - stopped by pressure. |
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1900hrs |
Dressing taken down : Free arterial bleeding from nicrotic area just below femoral canal.
Blood transfusion begun. Taken to theatre. |
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Opn: I.V. Pentothal: Vertical incision made directly on line of femoral artery - apparently bleeding from hole in its wall proximal to original ligature where ulcerative process had spread. This segment of femoral art. apparently fed by anastomotic blood from dup external iliac, pudendal and superficial epigastric branches.
The main trunk ligated & these branches as well.
Given blood - 1 litre
TOTAL blood since 14:09:43 = 30 litres. |
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25:10:43, |
Gen. cond. very good. |
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26:10:43 |
Early a.m. profuse discharge - offensive pus from stitch hole near mid line incision. Wd & stump redressed 0830 hrs. |
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1000 hrs |
Free bleeding commencing from region femoral canal. |
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Taken to theatre. Blood transfusion begun.
I.M.I. 20 ccs coagulam Ciba.
Opn : I.V. Pentothal
(1) Bleeding point found and controlled with mattress suture - ? superficial external pudendal artery.
(2) Prox. end Wd in mid line opened - track led to abscess deep in L. iliac fossa and upper pelvis . Drained through lower end of abdomen incision by large bone tube.
Given 1 litre of blood. |
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28:10:43 |
No more bleeding. Free discharge from abscess: Does not look so well. |
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30:10:43 |
Looks & feels well. Stump redressed. Tube in abdomen shortened. |
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04:11:43 |
T. 102 Headache. Sweats. Malaise - B.F.: No M.P. seen. |
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09:11:43 |
Tube out - little discharge. Stump healing well. Pressure sores improved. |
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11:11:43 |
OFF D.I. -- ON S.I. LIST |
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15:11:43 |
Temp. rising for last week. Feels well. Fluctuation, medial and post aspect of stump and tenderness - suggests abscess formation. Abdomen: scanty discharge only from mid line incisions. Good deal of induration in L.I.F. - mod. tenderness. |
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HB - |
12.5 Gms % |
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W.B.C.- |
7.500 |
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N - |
33% |
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L - |
58% |
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M - |
4% |
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E - |
4% |
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B - |
1% |
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16:11:43 |
Opn: I.V. Pentothal
Medial aspect of stump incised. No pus found - only gelatinous oedema of muscles & subcutaneous tissue.
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18:11:43 |
Rectal examination - N.A.D.
Profuse discharge of pus coming from bone fragments, i.e. from concellous bone of greater trochanter. Gen. cond. very good. |
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22:11:43 |
XRay:
"Metallic F.B. in S.T. below neck of femur. Erosion inferior border of neck & probable sequestrum medial to this erosion" |
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02:12:43 |
Gen. cond. good. Temp. elevated to 101 last two days. |
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07:12:43 |
Yesterday complained of some pain R. hypochondr.
Well otherwise. |
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H.B. |
12.3 Gm % |
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W.B.C |
11,000 |
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N : |
48% |
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E : |
19% |
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L : |
25% |
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M : |
8% |
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12:12:43 |
Feels very well. Stump healing in from edges - still some offensive discharge from femoral fragment, but less in amount. Pressure sores on back quite healed. Sore over Rt A.S.I..S.healing. |
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- E.T.M. Category X D. |
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Condition on Discharge:- Relieved. |
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Signature of Medical Officer:,....................... |
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J. GIBSON,Maj. |
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Date......................... |
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return to |
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