A brush with death in a midnight crash and a huge gash on his neck Silva never expected to live another day to relate his story, but HE DID!

Silva was a 27 year old young man who earned a living by driving his own three wheeled trishaw taxi. He used to work from morning and sometimes till midnight to earn a substantial income for his living. He has had many brushes with death like all 3 – wheeled trishaw taxi drivers in view of their reckless and careless driving. He had also seen many accidents on his daily routine especially at night. He never expected the same fate will befall him one day. Silva was mistaken. Due to his carelessness which he admits now and says, luckily, there were no passengers at the time of the accident.

Head on Crash at Midnight

On the 6^th of February 1995, late in the evening he received a hire from an office worker to take him home nearly 40 km away. He had dropped his client at his home at around midnight and had been on his return trip back home. Silva, tired and weary after a hard day’s work had been nodding as he was driving his trishaw and had suddenly fallen asleep.  He had crashed head-on to a stationary bullock cart. There was pandemonium following the accident. The trishaw had come to a sudden halt. The bull tied to the cart had escaped and ran amok. With all this and the loud sound created by the accident, Silva had woken up only to collapse a few minutes later. He could only remember that blood was gushing out from a large gash in his neck and his breathing was also noisy and difficult.

Good Samaritans to the Rescue

The injuries that Silva suffered were quite serious. The good Samaritans who witnessed the accident had come to his rescue. Silva had been bleeding profusely from the gash in the neck. There were no First Aid Kits, no Paramedics and no Ambulance to transport injured Silva to hospital. But they had done something sensible making use of what was available to stop his bleeding which I could safely say prevented him from bleeding to death. They had removed his T- shirt and wrapped it around his neck to stop the bleeding. That was an ingenious and useful first aid dressing, the only one available at that time. Then he had been carried on to another Trishaw and transported to the closest General Hospital for emergency care. Thanks to the good Samaritans, Silva was able to reach hospital in the nick of time and is alive today to relate his story.

Unable to Speak

On admission to the hospital he had recovered somewhat as the bleeding had stopped, but he had realized that he could not speak and breathing was noisy and difficult. The men who brought Silva to the hospital had no idea about him to give the necessary details required at the admission counter. As verbal communication was not possible, whatever details the hospital staff wanted had to be written on a piece of paper. He had been able to do this with great difficulty.

What were the Injuries

As Silva was asleep at the time of the accident, his head had suddenly moved forward in an uncontrolled manner. The deep gash in the neck had been caused by the sharp edge of the damaged glass of his windscreen which had been shattered to pieces. He had been resuscitated at the Emergency Department of that hospital and taken for emergency surgery. Silva was lucky. He had nearly escaped death on the spot as the injuries were serious. The doctors at the hospital had identified that all the important structures in the neck had been cut except the major blood vessels taking blood to the brain. The anatomical structures in the neck that had been cut completely were the Thyroid Gland, the Trachea (wind pipe), the Oesophagus (gullet), two important nerves associated with the functioning of the Larynx or the voice box (recurrent laryngeal nerves) and some superficial blood vessels.

Silva undergoes Emergency Surgery

At surgery, bleeding had been arrested, the damaged Thyroid Gland repaired, the gullet too had been repaired by bringing the two ends together with sutures. A tube was passed through the nose into the stomach via the injured gullet (nasogastric tube) to splint the repaired gullet and to feed him later. Also, a tube had been inserted to the damaged wind pipe to facilitate breathing. This is referred to as a Tracheostomy. With the surgery performed by the doctors at that hospital he had recovered from the near fatal injuries but developed problems that affected his life-style and employment.

Problems affecting Life Style

In view of the Tracheostomy he was not able to speak. That is no doubt a problem associated with this procedure and could not be avoided. Furthermore, the suturing of the cut ends of the gullet in the neck had resulted in a narrowing of the gullet. Many attempts had been made to stretch the narrowing of the gullet, a procedure referred to as dilatation of the oesophagus carried out under general anaesthesia. In view of the “block” in the gullet he was not able to take food and drink in the usual manner. To overcome this, a tube had been inserted in to his small intestine (Jejunostomy) through the abdominal wall so that food can be introduced in fluid form from a jug via a funnel connected to that tube. He was trained to do this procedure as and when he liked and when he felt hungry. The Tracheostomy tube too had to be cleaned and changed daily. He was trained in that too and had been able to change that tube by looking at a mirror when performing the procedure. He spent nearly two months in that hospital strictly adhering to the instructions of the doctors and hoping for recovery.

Silva leaves hospital in desperation

However due to constraints beyond the scope of the doctors, overcrowding in the ward like in any government hospital and in sheer desperation with his nutritional status worsening he had left that hospital against medical advise. He had spent another four months at home following the doctors instructions. In fact he was waiting for a letter or a phone call from the hospital for advise regarding readmission for further surgical procedures to give him permanent relief of his problems especially with the many tubes that he was carrying. Four months had passed by and there had been no communication. In fact he had been contemplating suicide when his relations decided to admit him to another hospital seeking solace and cure as he was unable to live with these tubes forever. Furthermore, he could not carry out his job as a 3- wheeled trishaw taxi driver.

PROBLEMS Tracheostomy tube – unable to speak Narrowing of the gullet – unable to take food via normal passage Problems associated with managing tubes that had been inserted Unable to perform his usual occupation as a Trishaw driver

Admitted to Sri Jayewardenapura General Hospital – 11^th August 1995

It is in that condition that Silva came to my clinic at the Sri Jayewardenapura General Hospital (SJGH) almost six months after his accident. This is nothing but Providence and God had given me the future care of Silva to take him out of the desperate situation that he was in.  I remember Silva’s mother’s words as she spoke to me in the clinic. She said, Sir, my son is suffering with these tubes, he cannot eat, he cannot speak and he is unable to carry out his occupation. Can you do something to relieve him of this suffering?  I could not give an answer to the questions she asked right-away without knowing what exactly had happened and what had been done. I went through all the previous hospital notes and came to understand the situation better.  I was confident that I could cure Silva and take him back to “normal life”. I informed Silva’s mother to admit her son to my ward and that everything necessary will be done to take him out of the desperate situation that he was in.  Those words brought “tears of joy” to the mother and she worshipped me in the traditional Sri Lankan way before they left my clinic to the ward.

Condition of Silva on Admission

Silva had many tubes hanging out of his body. He was wasted and appeared depressed. He showed me how he was feeding and his technique of changing the Tracheostomy tube.

Investigations Carried Out

Further Surgery Planned

Many attempts had been made at the previous hospital to treat the narrowed gullet by non surgical means. Therefore, I did not attempt that procedure again. The only permanent solution for this patient would be to have his gullet replaced by another organ like the stomach. This is called Transposition of the stomach or in more simple terms, to take the stomach with its blood supply up through the chest and connect in the neck to the gullet above the narrowing. It is indeed a major reconstructive procedure, but that was the only way for him to be able to get rid of those tubes hanging out of his belly and take food in the normal way like anyone else. The removal of the Tracheostomy tube was another procedure, but had to be done later. Silva agreed to the procedure. There was no other choice!

Postoperative Care and Feeding

It was a major surgical procedure that took six hours. He was managed in the Intensive care Unit for the first 48 hours and then transferred to the ward for further management. With further care in the ward Silva recovered and after two weeks the time had come to give his first feed – a small quantity of distilled water by mouth. It was my practice to give the first feed after this type of surgery and it was no different for this patient. The ward staff was ready for this and during the ward round I gave him the first sip of water. To the satisfaction of Silva and everyone else, Silva swallowed that sip of water without any difficulty.

Gradually the quantity of water given was increased and later other forms of nutritious fluids were introduced orally. Gradually we changed over to semi solid food and then to solid, the most important being our stable diet rice which Silva had not eaten for more than six months. He was yearning for a plate of rice and curry and that day was reached. It was probably the “happiest day in his life” and we too were happy to see our friend Silva eating again!

Tubes, Jug and Funnel – a Museum piece

All these items were not needed anymore and were removed and given to Silva to be kept with him to remember the difficult times he went through for over six months unable to eat and drink. When I met Silva recently, he told me that he is still preserving these items at his home.

Silva leaves hospital (SJGH)

After nearly two months at the SJGH Silva left hospital. He was able to eat and drink, but he was not able to speak as he was having the tracheostomy tube in view of the damaged wind pipe. Furthermore, his voice box was also not functioning effectively as the nerves to the vocal cords were damaged. This needed further surgery and that had to be done by an ENT Surgeon. Therefore I referred him to the ENT Surgeon at SJGH, Dr Asoka Jayasena. He was of the opinion that the removal of the tracheostomy tube and the surgery on the larynx should not be done immediately. Silva continued with that tube as before and had corrective surgery on his larynx about six months later.

Complete Recovery

Following that procedure he was once again free of all tubes, but did not have the stamina to go back to his previous occupation as the driver of a three wheeled taxi. He decided to recuperate at home. In all, he had been anaesthetized eighteen (18) times since the injury till his recovery. It was only after a period of nearly twenty months that he decided to start work. By then he was in a fit condition but had to purchase a new three wheeler. 

Silva Buys a New Three Wheeled Trishaw Taxi

Silva had to purchase a new vehicle. He obtained a loan, purchased a new vehicle and the same day he visited SJGH to meet me. It was a surprise for me when he said, Sir I have bought a new three wheel trishaw taxi and I want you to be the first passenger. I agreed and got in to be taken on a short trip round the hospital premises where he had successful surgery. For me that was a happy day too and that trip with Silva as the driver of his new vehicle gave me immense happiness than going in the best vehicle in the world, a happiness no money could buy.

THAT IS SILVA’S GRATITUDE!

Meeting after Twenty Five Years – 2020

Silva was in touch with me through phone and used to meet me on and off. On my request, he visited me at my residence on 19/9/2020. I was happy to meet him. I was able to refresh details about the accident and the treatment at the hospital where he had emergency care. He also gave his verbal consent to publish his story in my blog titled “A Surgeon’s Tales” with his photographs.

A Note about Road Accidents in Sri Lanka

Road traffic accidents have reached horrendous proportions in our country with one person reportedly killed every 3–hours and double or treble that number seriously wounded and ending in emergency wards with deep wounds, fractures and multiple injuries never to lead a normal life again. Many such victims are drivers and passengers of three wheeled trishaw taxis.

Silva was lucky. He recovered after a nasty accident to drive his “wheel” once again. I hope he will not sleep on the wheel once again.

Acknowledgement – I thank Silva for giving me all the necessary details to write this story. I also thank the staff in my ward No.8 at SJGH for the care given to Silva during his hospital stay which made my task easier.

Dear Reader, you might be interested in the next story, titled : ‘TREATING WAR VICTIMS PART1- EXPLOSIVE DEVICES’