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The Trach Incision -


Tony Frank
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http://www.primary-surgery.org/ps/vol2/html/sect0017.html

Would we consider Perry "inexperienced"???

OPENING THE TRACHEA

If you are inexperienced, make a 5 cm vertical incision starting just below the patient’s cricoid cartilage, as in A, Fig. 52-4. When you have had several successes, make a transverse incision 5 cm long 2 cm below the border of his cricoid cartilage. Cut through the patient’s subcutaneous fat, and his cervical fascia ©.

CAUTION! (1) From now on use blunt dissection. Use it to raise short flaps and expose his anterior jugular vein and the underlying muscles.

Use blunt dissection to define and separate the fibrous median raphe between his right and left sternohyoid muscles. His sternothyroid muscles lie slightly deeper, find them and retract them laterally. You will now see the isthmus of his thyroid gland and part of his trachea. They vary considerably.

If the isthmus of his thyroid is small, there is no need to divide it.

If the isthmus of his thyroid is large and interferes with your approach to his trachea, divide it. Make a small horizontal incision through his pre–tracheal fascia over the lower border of his cricoid cartilage. Put a small haemostat into the incision and feel behind his thyroid isthmus and its fibrous attachment to the front of his trachea (D). When you have found the plane of cleavage, use blunt dissection to separate the isthmus from the trachea. Put a large haemostat on each side of the isthmus, and cut it. Later, oversew the cut surfaces or tie them (E).

Put sutures into the skin edges ready to close the wound round the tube later.

Insert a tracheal hook below his cricoid cartilage and pull his trachea forwards and upwards (not illustrated). Have a sucker and a catheter ready.

CAUTION! Control all bleeding before you open the patient’s trachea. Cut the membrane below its second or third ring transversely, and keep the sucker near the opening. Then stand clear. If there is blood in his trachea, he will cough it everywhere.

Turn a flap (F) containing his second tracheal ring downwards and insert the tube. The flap will act as a guide to direct the tube into his trachea and will make changing it easier. A flap largely eliminates the great danger of a tracheostomy, which is inability to replace the tube quickly when it has come out accidently. When the tube is safely in place, stitch the flap to his skin.

CAUTION! (1) Don’t disturb his first tracheal ring. (2) Don’t remove any trachea. (3) Don’t incise more than 40% of the circumference of his trachea, or severe stenosis may follow.

Inject 2 ml of lignocaine into the stoma in his trachea; he will tolerate the tube more easily with his mucosa anaesthetized.

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From what I understand, this is one of the most overblown issues in all of JFK medical evidence.

When Dr. Perry, Dr.  Carrico, and Dr. Baxter say that the trach incision was certainly less than 4 centimeters, it seems like they consider the trachea incision a completely separate thing from the slit incised across the neck.

Mr. SPECTER - Dr. Perry, you mentioned an injury to the trachea.
Will you describe that as precisely as you can, please?


Dr. PERRY - Yes. Once the transverse incision through the skin and subcutaneous tissues was made, it was necessary to separate the strap muscles covering the anterior muscles of the windpipe and thyroid. At that point the trachea was noted to be deviated slightly to the left and I found it necessary to sever the exterior strap muscles on the other side to reach the trachea. I noticed a small ragged laceration of the trachea on the anterior lateral right side. I could see the endotracheal tube which had been placed by Dr. Carrico in the wound, but there was evidence of air and blood around the tube because I noted the cuff was just above the injury to the trachea.

Severing the exterior strap muscles? Most diagrams of this show those on the sides of the level of the chin. My chin is at least 5 centimeters across. This could all have a simple, common sense explanation.

 

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"Dr. Perry made an incision across the bullet wound, just large enough to accommodate a breathing tube. During a phone conversation in 1966 with author David Lifton, Perry said the incision was "two to three centimeters" wide [4, p. 272]. Drs. Paul Peters and Robert McClelland, also present in trauma room one, said the incision was "sharp" and "smooth," respectively [4, p. 275]. After the breathing tube was removed, the incision closed, revealing the original wound in the throat, as described by Drs. Charles Crenshaw and Malcolm Perry. Dr. Crenshaw recalled, "When the body left Parkland there was no gaping, bloody defect in the front of the throat, just a small bullet hole in the thin line of Perry's incision" [5, p. 54] Dr. Perry described the bullet wound in the throat as "inviolate" [6, pp. 100-101]."

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14 hours ago, Ray Mitcham said:

"Dr. Perry made an incision across the bullet wound, just large enough to accommodate a breathing tube. During a phone conversation in 1966 with author David Lifton, Perry said the incision was "two to three centimeters" wide [4, p. 272]. Drs. Paul Peters and Robert McClelland, also present in trauma room one, said the incision was "sharp" and "smooth," respectively [4, p. 275]. After the breathing tube was removed, the incision closed, revealing the original wound in the throat, as described by Drs. Charles Crenshaw and Malcolm Perry. Dr. Crenshaw recalled, "When the body left Parkland there was no gaping, bloody defect in the front of the throat, just a small bullet hole in the thin line of Perry's incision" [5, p. 54] Dr. Perry described the bullet wound in the throat as "inviolate" [6, pp. 100-101]."

Yes, but it really sounds like the trach incision is being talked about as a completely different thing than the anterior neck incision.

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Micah

" Dr. PERRY - Yes. Once the transverse incision through the skin and subcutaneous tissues was made, it was necessary to separate the strap muscles covering the anterior muscles of the windpipe and thyroid. At that point the trachea was noted to be deviated slightly to the left and I found it necessary to sever the exterior strap muscles on the other side to reach the trachea. "

It is necessary, when reading medical evidence regarding the trachea, to be able to distinguish between a "tracheotomy" and a "tracheostomy", in order to avoid confusion.

A tracheotomy is the procedure of surgically opening the skin overlying the trachea and then making an opening in the trachea to accommodate the tracheotomy breathing tube.

A tracheostomy is the actual site of this opening of the trachea, and the breathing tube inserted therein.

In other words, a tracheotomy is performed to establish a tracheostomy.

In the quote from Perry above, he clearly states that he made a transverse (horizontal) incision in the skin and subcutaneous tissue overlying the trachea, just as can be observed in the autopsy photos, although the autopsy photos seem to show a much larger incision than the 2-3 cm. (.8-1.2 inches) incision described by Perry et al.

If you made a 2-3 cm. incision transversely across the trachea, you would have cut halfway through the trachea.

BTW, why do you think the trachea was deviated to the left, so much so that Perry had to "sever the exterior strap muscles on the other side to reach the trachea"?

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1 hour ago, Robert Prudhomme said:

Micah

" Dr. PERRY - Yes. Once the transverse incision through the skin and subcutaneous tissues was made, it was necessary to separate the strap muscles covering the anterior muscles of the windpipe and thyroid. At that point the trachea was noted to be deviated slightly to the left and I found it necessary to sever the exterior strap muscles on the other side to reach the trachea. "

It is necessary, when reading medical evidence regarding the trachea, to be able to distinguish between a "tracheotomy" and a "tracheostomy", in order to avoid confusion.

A tracheotomy is the procedure of surgically opening the skin overlying the trachea and then making an opening in the trachea to accommodate the tracheotomy breathing tube.

A tracheostomy is the actual site of this opening of the trachea, and the breathing tube inserted therein.

In other words, a tracheotomy is performed to establish a tracheostomy.

In the quote from Perry above, he clearly states that he made a transverse (horizontal) incision in the skin and subcutaneous tissue overlying the trachea, just as can be observed in the autopsy photos, although the autopsy photos seem to show a much larger incision than the 2-3 cm. (.8-1.2 inches) incision described by Perry et al.

If you made a 2-3 cm. incision transversely across the trachea, you would have cut halfway through the trachea.

BTW, why do you think the trachea was deviated to the left, so much so that Perry had to "sever the exterior strap muscles on the other side to reach the trachea"?

If Perry was severing the strap muscles, it sounds like we're talking about an incision on the neck at least 5 centimeters.

 

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Image result for strap muscles of the neck

Perry was likely severing part of the left sternothyroid muscle. With the trachea deviated to the left, the site on the trachea for making the incision would be covered by the sternothyroid muscle. Why do you think the incision on the neck would have to be 5 cm.?

Have you figured out why the trachea was deviated to the left?

Edited by Robert Prudhomme
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5 hours ago, Robert Prudhomme said:

Image result for strap muscles of the neck

Perry was likely severing part of the left sternothyroid muscle. With the trachea deviated to the left, the site on the trachea for making the incision would be covered by the sternothyroid muscle. Why do you think the incision on the neck would have to be 5 cm.?

Have you figured out why the trachea was deviated to the left?

Look at the location of the strap muscles in relation to the length of the chin. My chin is about 5 centimeters. If Dr. Perry was cutting both sides of the strap muscles, that sounds like it could totally be consistent with the 6.5 cm wound with widely gaping, irregular edges if you also consider the insertion and removal of the trach tube.

Edited by Micah Mileto
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Why would Perry cut through the entire strap muscle if he was only attempting to uncover the slightly deviated trachea? How far do you think the trachea was deviated to JFK's left?

Surgically speaking, it would be rather foolish to cut through the entirety of the sternothyroid muscle as, should JFK have lived, this muscle would have to be reattached at some point in time. Far easier to sew a small cut on the side of this muscle than to reattach the entire muscle, and healing would take far less time.

P.S.

Reading your post again, I get the impression you believe Perry cut the strap muscles on either side of the trachea. Is this what you believe?

Edited by Robert Prudhomme
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11 minutes ago, Robert Prudhomme said:

Why would Perry cut through the entire strap muscle if he was only attempting to uncover the slightly deviated trachea? How far do you think the trachea was deviated to JFK's left?

Surgically speaking, it would be rather foolish to cut through the entirety of the sternothyroid muscle as, should JFK have lived, this muscle would have to be reattached at some point in time. Far easier to sew a small cut on the side of this muscle than to reattach the entire muscle, and healing would take far less time.

P.S.

Reading your post again, I get the impression you believe Perry cut the strap muscles on either side of the trachea. Is this what you believe?

I don't know. But there is a difference between a tracheotomy/trach incision, like what Perry and friends remember as being about 2-3 centimeters, and the incision on the neck. If there was any cutting of the strap muscles on the sides of the windpipe, that really sounds to me like that could be consistent with the meaty wound in the autopsy photos. If Lifton let on in his 1966 interviews that he was talking about the neck incision, not just the windpipe incision, then the doctors may have said "oh yeah, if that's what you're talking about, that was longer than 5 centimeters".

Edited by Micah Mileto
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"......... I found it necessary to sever the exterior strap muscles on the other side to reach the trachea. "

Translated, he only cut the sternothyroid muscle on one side of the trachea. If the trachea was deviated to JFK's left, and was hiding behind the left sternothyroid muscle, and Perry was trying to access the trachea, it would be a safe bet, I believe, that he partially severed the left sternothyroid muscle.

Now, aren't you even a little curious as to why JFK's trachea was deviated to his left?

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Just now, Robert Prudhomme said:

"......... I found it necessary to sever the exterior strap muscles on the other side to reach the trachea. "

Translated, he only cut the sternothyroid muscle on one side of the trachea. If the trachea was deviated to JFK's left, and was hiding behind the left sternothyroid muscle, and Perry was trying to access the trachea, it would be a safe bet, I believe, that he partially severed the left sternothyroid muscle.

Now, aren't you even a little curious as to why JFK's trachea was deviated to his left?

It's obviously doesn't come close to being as cut-and-dry like Lifton or Horne lets on. The incision in the neck was probably longer than 2-3 centimeters.

 

Why was the trachea deviated to the left?

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