By Dr. Nqobile Manzini, Cardio-Thoracic Surgeon
Its 1am in the night and the ambulance brings in a woman who has been stabbed 27 times over her neck, face and chest area, the so called crime of passion. She is walking however on a face mask receiving oxygen and 2 IV lines from the Ambulance crew. A few minutes in we are called on her resuscitation, she has developed a tension pneumothorax. A chest drain is inserted and she is saved, at least this one is for now.
Many are stories of either a trauma bay or Thoracic ICU that starts in the same way or come in, in extremis where the gender based violence survivor/victim is fighting for his or her life. This article is here to shed light on different injuries that can be sustained from the chest and neck area from gender based violence and possible consequences.
The face and the neck are the usual targets especially in women — these have in many occasions also translated to the chest. Trauma to the neck and chest can either be penetrating (stab wounds with knives, gunshot, or any sharp object) or blunt, usually with fists or large objects, sometimes being thrown onto the floor or large objects. Strangulation on the neck counts as blunt trauma.
Penetrating Trauma
Penetrating trauma can cause injury to the trachea (breathing pipe) in the neck area, direct lung laceration and heart stab or stab into the great vessels (aorta, its branches and pulmonary artery). The extent of the injury depends on the sharp object, velocity and the repetition of the action. The person who has multiple stabs in the lung will have multiple lung lacerations which results in pneumothorax (air around the lungs) — this may not be appreciated early from other people but may end up causing tension pneumothorax, which is deadly as the air around the lung compresses both the lung and the heart with great vessels and causes the complete stop of the heart (cardiac arrest).
The other complication is haemothorax (blood around the lung in the pleural space) which may be small or large. The small haemothorax can usually be managed by the body and dissolves with time; however the large haemothorax requires drainage. If it is early and still bloody it can be drained with a pipe called an intercostal drain, or when clotted it will need evacuation and washout in theatre under general anaesthesia.
Penetrating injury into the heart and the great vessels causes bleeding. The bleeding can either be small and contained or can be great and life-threatening. What sometimes saves the person is the system that is injured — if it is the low pressure system such as the pulmonary system, the bleeding may stop and be contained. However, a stab into the left side of the heart or the aorta is detrimental. Some people never make it to the clinic or trauma centre; they die on their way to seek help. If one is lucky and the injury in the great vessel is small enough to be contained, they may make it to the hospital — however surgery may be necessary to prevent pending rupture and death thereafter.
Blunt Chest Trauma
Blunt chest trauma is a completely different challenge, because sometimes what you see on the outside tells nothing about what is going on internally. The person may receive blows on the chest and sustain lung contusion which may cause already existing lung illness to worsen — e.g. bullous lung disease with blebs that rupture on acute rise of intra-thoracic pressure. Some people get bruises while there are underlying rib fractures; these can also cause lung lacerations and pneumothorax.
Pain from blunt chest trauma is not recognised enough, and how this can affect ventilation and breathing is often overlooked. If one has chest pain from trauma they usually do not take deep breaths — as a result the underlying lung does not open well, secretions pool and the lung becomes secondarily infected.
Blunt chest trauma to the heart and great vessels can cause shear stress tears which predispose to later aneurysm or even rupture.
A Systemic Problem That Needs All of Us
There is so much that can be studied from GBV-based trauma. It is unfortunate that this is a multifaceted systemic problem and needs to be attacked from all angles — from the societal level, the family and down to the individual.
Love is meant to be a great force that builds and grows society. The opposite end of its toxicity and the lives that are affected by it really need all of us to work together with the survivors and heal the system that has allowed for such to breathe in our communities.
Our children deserve a better world, with both parents in harmony — and it starts with us.