Researching fatal injuries for story

Atamasco,

Unfortunately, potentially fatal gunshot wounds are significant enough that most patients do not get over them in just a few days.

Usually, injuries to the extremities are not life threatening.

Head shots are almost always fatal. Occasionally, patients will survive a gunshot wound to the head, but they usually are left with cognitive defects. And, it would take more than a few days to be up an about, if the patient did survive.

So, that basically leaves chest and abdominal wounds.

Though abdominal wounds may not be fatal right off the bat, the patient usually develops peritonitis from leakage of bowel contents into the peritoneal cavity. Death from peritonitis usually takes several days to occur and is an agonizing way to die. This is why all gunshot wounds which penetrate the peritoneal cavity have to be formally explored (called an ex-lap; an exploratory laparotomy). Then, any perforations of the bowel can be repaired and the cavity can be cleansed. The use of antibiotics is actually secondary to the surgical debridement.

I guess it could be conceivable that the patient sustained a gunshot wound which did not perforate any loop of bowel. In that case, the patient would be very sore from the trauma of the wound, but would be able to start moving around in a fairly short amount of time. But, again, this would be one of those very rare “lucky” shots (almost unbelievable). Of course, it is possible to sustain a gunshot wound to the abdomen, which does not enter the peritoneal cavity. It would basically be a grazing shot, through the subQ tissues along the side of the abdomen. But, this would not be a potentially fatal wound, expect in the aspect that all gunshot wounds are conceivably life threatening (unlucky shot which hits an artery or the patient develops an overwhelming infection from a grazing wound).


Then you have the chest wounds. Unfortunately, there are a lot of vital organs in the chest, but there are some areas which do not have too much “stuff”. Shots to the heart, mediastinum, or the great vessels would be fatal immediately to within just a few moments. Shots which go through the lungs are usually not immediately fatal. But, usually the patient develops a pneumothorax (air in the thoracic cavity), a hemothorax (blood in the thoracic cavity), or a pneumohemothorax (both air and blood in the thoracic cavity). As these develop, the patient goes into respiratory distress and eventually dies from hypoxia, if not treated.

However, it is conceivable that a patient could have a lung shot, which results in a tension pneumothorax, where a quick thinking medic relieves the pressure with a needle in the chest. Then a “flutter valve” dressing is applied to the wound to prevent the recurrence of the tension, and the patient lives. She would not be real active till definitive treatment is done, but she could move around a little.


Hope that helps some. Good luck with your writing.

Ah, thank you very much this is extremely helpful! I was considering either a shot to the lung or a wound that caused a lot of bleeding, like a shot to an artery or a major vessel. I am thinking a shot to the lung would be the more likely in the heat of battle.

Assuming that the patient suffered from pneumothorax, had a quick-thinking medic, and got the definitive treatment within the next 24 hours, would she be able to walk around relatively soon?

If I'm reading this correctly, the medic would stab a needle through the chest and a hollow tube would then be inserted through the hole?

Also, sorry to be a bother: What, exactly, would the definitive treatment entail?

Atamasco,

The large bore needle is inserted in the second intercostal space (just below the clavicle) in line with the nipple. This will miss the subclavian artery and the compressed lung tissue. Any large bore needle can be used. Once the pressure is release, with a “rush of air”, the needle does not have to be left in place, as long as the proper dressing is applied. In some cases, the tension pneumothorax will return, thus to prevent having to stick the patient over and over, the needle is left in place. Some advocate the use of an IV catheter, so that the catheter can be left and the metal needle withdrawn. But, these are not very stout and often get bent because a syringe has to be left on to occlude the catheter. So, the ER services have developed needles which actually have a stopcock on them and they can be left in place, taped down or sewn down to the chest. These are actually part of some special ops medic’s medical kits.

So, there are several scenarios that could take place in terms of the needle usage.

Once the lung is reinflated, most patients feel pretty good. Sure, they are sore from the trauma of the gunshot wound, but they can once again breathe. If necessary, the patient could move around some, probably not too fast nor for too long.

The definitive treatment for a pneumothorax is a chest tube (also called a tube thoracostomy). The chest tube is then attached to a set of bottles (called a Gomco) or a commercially made suction pump. Many Special Forces medics are trained to place chest tubes. If the patient has to be transported (especially by air) in some cases, the suction apparatus is changed to an Heimlich valve. This is a very small device with goes on the end of the chest tube, which allow air to go out, but not come back in. Some medics affectionately call it a duck call, because you can blow on it and make duck like sounds. If you Google “Heimlich valve picture” you can get an idea of what it looks like. It is about the size of a small flashlight.

Usually, the patient will have to have the chest tube in place for many days. So, if the patient is going to be in one place for a week to 10 days, the chest tube treatment can begin. Otherwise, patients are usually evac’d back to a place where they can rest with the chest tube in place. Again, in necessary situations, a soldier would be able to do some activity once the needle decompression was conducted. They would hurt from the gunshot wound of course. And, if the tension pneumothorax reaccumulated, they would become short of breath very quickly and would have to open the stopcock or reinsert the needle. The needle decompression is essentially a life saving temporary measure, till a chest tube can be placed.


Hope that was not too confusing.

Good luck.

Not at all, that's perfect. I have a clear idea now of how this part of the story will go. I have one last question. In this procedure, what would be done with the bullet hole itself? If it's going straight through the lung, I'm assuming you'd have to patch that first to make sure the needle to the chest actually works. I don't know if it's more ideal that the bullet go all the way through to exit the body, or if it stops in the chest cavity.

Thank you very much for your help.

Atamasco,

Depending upon the caliber of the weapon and how far away the shooter was from the victim, the round may only have an entrance hole or it may go all the way through and have both an entrance and exit hole. The exit hole is almost always bigger than the entrance hole. There is a whole lecture on how tissue reacts to ballistics, so I won't bore you on that. Just to say that a patient who takes a close up, high muzzle velocity round (i.e. M16) to the unprotected chest will usually not live, because the cavitary effect usually totally destroys a significant amount of tissue (just blows it apart, often with a huge exit wound). The lower muzzle velocity rounds tend to bore through the tissue, not producing the large cavitary effect. In these, the entrance and exit holes are roughly the same size (if there is an exit hole at all). An M16 round from a very far distance would lose a lot of its muzzle velocity, and would then act more like a low velocity round.

Also, contrary to the movies, bullets do not have to be removed. In fact, most are left alone. The wound tract is debrided of foreign material, such as clothing, but further trauma from looking for the bullet is not done. I always have to laugh when I see actors blindly grabbing for bullets. This causes a lot more damage than it helps. Control the bleeding with direct pressure and then dress the wound (don’t keep looking at it, as that just stirs up the bleeding again). Once in the OR, then the wound can be formally explored. Arterial bleeds are also not blindly clamped, mainly because major nerves run with major arteries. So, clamping a nerve would be a bad thing (in terms of good and bad). If an arterial injury cannot be controlled with direct pressure, a tourniquet is used. Tourniquets can be left on for a max of about 4-6 hours, without sacrificing the limb (we routinely use tourniquets in extremity surgery for up to two hours, without any problems). Over four hours and you are really pushing the limits, as the patient will probably have problems with reperfusion syndrome (the toxins from the breakdown of hypoxic tissues are released into the body when the tourniquet is let down). Only in cases where the patient is going to die in the next few minutes as a blind clamp ever tried. If you are a surgeon, it is better to dissect out the artery and gain proper control of it, which can actually be done fairly quickly. An interesting fact about artery injuries: complete arterial transections do not bleed as much as partial arterial injuries (a nick in the artery). When an artery is cut in half, the muscle in the wall of the vessel clamps down and occludes the artery. But, if it is just nicked, the muscle cannot clamp down, so blood is just pumped out with each heart beat.


As to the chest wound(s), yes, they have to be dressed with a specific type of dressing. Most medics carry a chest wound dressing, which is a type of occlusive dressing, called an Asherman seal. In the old days, a Vaseline dressing was made to occlude the hole(s). But, these are often messy (in a field environment) and do not stick very well. But, in a pinch, they can still be used. The Vaseline is placed on a gauze dressing, which is placed over the hole. Some sheet of plastic (army medics are taught to use the outer pouch of an MRE - Meal Ready to Eat) or other nonporous material is placed over the gauze. The dressing is then taped down on three sides, with the forth left open. Theoretically, the air could escape from the chest through the dressing, but when the patient breathed in, the dressing would be sucked down, occluding the wound. They did not work as well as intended. But, you may still see this referred to in some of the literature. They are sometimes referred to as a flutter dressing.

The Asherman seal is a commercial flutter dressing. This is a specially designed device that adheres to the chest wall and, through a valve-like mechanism, allows air to escape but not to enter the chest when the patient breathes.

Sometimes, just using the Asherman seal is all that is needed to treat a chest wound. But, if the patient develops a tension pneumothorax, then the needle thoracostomy (decompression) needs to be done.

The reason a tension pneumothorax is such a life threatening emergency is that as air accumulates in the pleural cavity it compresses the lung tissue down to the size of a softball. However, you can live with just one lung without too many problems. But, as more tension builds up, the mediastinum gets shifted over to the uninjured side of the chest, compressing the “good” lung, the heart, and the great vessels. Some of the clinical signs which medics/physicians look for in diagnosing a tension pneumothorax include: no breath sounds on that side (but this is also seen in an hemothorax), a tympanic sound to the chest with percussion (a hemothorax has a dull sound), tachypnea (rapid breathing), shallow breathing, confusion or loss of consciousness, dusky (bluish hue) lips, and deviation of the trachea. As the chest contents get moved over, the trachea in the neck also gets pulled over. You may hear in ER shows, “he has a deviated trachea!” when they are doing an assessment of a chest wound. This is to tell everyone that the patient most likely has a tension pneumothorax. So, someone grabs a 14 gauge needle and jabs it into the chest, with a satisfying “rush of air”. (It actually is kind of satisfying.) Then, the resident cuts a hole in the side of the chest (in the “5th or 6th intercostal space in the midaxillary line”) and puts in a chest tube. Then he yells at the nurse to hook it up to suction (or a Gomco or any of the other commercial portable suction devices). In a field setting, if they did not have the portable suction device, a Heimlich valve would be placed. Remember, the chest tube does not have to be put in immediately, it can be delayed for a little while, as long as the tension in managed.


Sorry, I got carried away, thought I was teaching ATLS (Advance Trauma Life Support) again. Hope that answers your question. If you have any more questions, I’ll be happy to answer them, if I can.

Good luck with your writing. Wishing you the best.

You have been beyond helpful, thank you so much! Another forum kicked me off for trying to do research, so I am extremely grateful for all your help. Your response brings up another question: How quickly could a tension pneumothorax develop after an Asherman seal is applied, assuming it didn't do the trick? And, does the Asherman seal remain on the chest even after the thoracostomy and chest tube installation?

Seriously, thank you very much this has been extremely informative.

Atamasco,

Yes, the dressing is left on until the body heals the wound. Remember, the chest tube is left in for a week to 10 days. If the wound is really large, the surgeon may put a purse-string suture in it to close it down some, then put a dressing on over that. If the patient has to be taken to the OR for some reason, the surgeon may go ahead and close the wound at that time.

A tension pneumothorax can develop very rapidly (within 15 to 20 minutes) or it may not show up for several hours to a day after the initial injury. This is why the patient has to be continuously monitored or check on often. The last thing you want to do is dress a chest wound, put the patient in a quite corner, only to come back in a couple of hours to find him dead (unfortunately, it happens).

Again, good luck with your writing.

Thank you very, very much. This is perfect. I sincerely appreciate all your help.

No problem. Glad to be of help, as it actually keeps me busy and out of trouble (lol).

Good luck with your book.

Alright, this is (probably...maybe) my last question. In another scene, a male character gets shot in the neck. The gunner is standing directly in front of him, about 10-20 feet away. This character is definitely going to die, but I want to know how long I have before he's dead, assuming the bullet did not leave an exit wound, and the cause of death is either suffocation or blood loss.

And I'm very sorry if this question is in any way disrespectful. I'm just trying to get a grip on what is and is not stretching the limits of believability.

Atamasco,

No problem.

The neck is a very dangerous place to have a wound in. Few emergencies pose as great a challenge as neck trauma. Because a multitude of organ systems (e.g., airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound can cause a lot of problems. Seemingly innocuous wounds may not manifest clear signs or symptoms and potentially lethal injuries can be easily overlooked or discounted. Airway occlusion and exsanguinating hemorrhage pose the most immediate risks to life.
The carotid artery and jugular veins (internal and external) run up both sides of the neck, just lateral to the trachea (windpipe) and esophagus. You can feel for your pulse in that area to get an idea of where the artery is located. If you stand in front of a mirror, take a deep breath, hold it, and do a valsalva maneuver (strain a little), you can watch your jugular veins fill up and become distended.

So, lateral to the vessels you basically just have muscles (the sternocleidomastoid muscles, the scalenes, the levators, and the strap muscles of the neck). Medial to the vessels, you have all of the vital structures. There is the vertebral column with the spinal cord in it, the trachea, the esophagus, the phrenic nerve to the diaphragm, and the vagus nerve to the heart.

Thus, a gunshot which transects the spinal cord (high spinal injury) will cause the patient to be totally paralyzed immediately. He will collapse, unable to move or breathe. Thankfully, these patients are usually not conscious and die within a few minutes (respiratory arrest, they can’t breathe).

A patient who sustains a wound to the lateral neck, just within the muscles, usually survives and does well overall.

A patient could have a wound where he has an injury to the jugular vein, which would be a low pressure injury, who could conceivably suffocate on accumulating blood in and around the trachea. That would take several minutes or even several hours to occur. If a medial person got to him with some suction and controlled the bleeding with direct pressure, he could live. He would have to have his airway controlled with intubation.

Carotid artery injuries are the ones where patients bleed out pretty quickly. With every heart beat, blood squirts out of the artery. Even with direct pressure, these patients usually die. Occasionally, if surgical attention is immediately available, a surgeon can obtain control of the artery. But, the patient will usually need a massive transfusion of blood products.


So, if a person was shot with a low caliber hand gun, death could range from basically immediately to several hours later, depending upon what structures were injured. If you read the statistics, we are actually doing pretty well at saving these patients if they can reach medical attention quickly. So, you have as much (or as little) time you need, to kill off your character.

Most persons, who are shot at close range with a military weapon (M16) in the neck, sustain such massive trauma that they die almost immediately. Again, this is due to the ballistic effects of the weapon.


Hope this information helps. If something is not understandable, let me know, I’ll try to clear up that specific point.

Thank you! That is, once again, perfect. Very informative. You have been beyond helpful. I will be sure to post other questions in the future, should they arise. Again, I sincerely appreciate your help! ^^

Okay, I have another question about the tension pneumothorax scenario, as I am now writing about it in earnest and have come across something confusing.

So, the patient develops a tension pneumothorax after an Asherman's seal is applied, and shortly thereafter the bore needle is inserted to decompress the chest cavity. The medic then gets to work on installing a chest tube with a Heimlich valve. The Asherman's seal is left over the bullet wound. But what happens to the wound created by the bore needle? Is the needle left in even after the chest tube is installed, or is it taken out before the chest tube is installed? And, if it's to be taken out, how does the medic then dress the wound created by the bore needle?

Also, if a chest tube is installed, how long before the patient is able to be sexually active again?