What I Saw Treating the Victims From Parkland Should Change the Debate on Guns
As I opened the CT scan last week to read the next case, I was baffled. The history simply read “gunshot wound.” I have been a radiologist in one of the busiest trauma centers in the United States for 13 years, and have diagnosed thousands of handgun injuries to the brain, lung, liver, spleen, bowel, and other vital organs. I thought that I knew all that I needed to know about gunshot wounds, but the specific pattern of injury on my computer screen was one that I had seen only once before.
In a typical handgun injury, which I diagnose almost daily, a bullet leaves a laceration through an organ such as the liver. To a radiologist, it appears as a linear, thin, gray bullet track through the organ. There may be bleeding and some bullet fragments.
I was looking at a CT scan of one of the mass-shooting victims from Marjory Stoneman Douglas High School, who had been brought to the trauma center during my call shift. The organ looked like an overripe melon smashed by a sledgehammer, and was bleeding extensively. How could a gunshot wound have caused this much damage?
The reaction in the emergency room was the same. One of the trauma surgeons opened a young victim in the operating room, and found only shreds of the organ that had been hit by a bullet from an AR-15, a semiautomatic rifle that delivers a devastatingly lethal, high-velocity bullet to the victim. Nothing was left to repair—and utterly, devastatingly, nothing could be done to fix the problem. The injury was fatal.
A year ago, when a gunman opened fire at the Fort Lauderdale airport with a 9 mm semiautomatic handgun, hitting 11 people in 90 seconds, I was also on call. It was not until I had diagnosed the third of the six victims who were transported to the trauma center that I realized something out of the ordinary must have happened. The gunshot wounds were the same low-velocity handgun injuries that I diagnose every day; only their rapid succession set them apart. And all six of the victims who arrived at the hospital that day survived.
Routine handgun injuries leave entry and exit wounds and linear tracks through the victim’s body that are roughly the size of the bullet. If the bullet does not directly hit something crucial like the heart or the aorta, and the victim does not bleed to death before being transported to our care at the trauma center, chances are that we can save him. The bullets fired by an AR-15 are different: They travel at a higher velocity and are far more lethal than routine bullets fired from a handgun. The damage they cause is a function of the energy they impart as they pass through the body. A typical AR-15 bullet leaves the barrel traveling almost three times faster than—and imparting more than three times the energy of—a typical 9mm bullet from a handgun. An AR-15 rifle outfitted with a magazine with 50 rounds allows many more lethal bullets to be delivered quickly without reloading.
I have seen a handful of AR-15 injuries in my career. Years ago I saw one from a man shot in the back by a SWAT team. The injury along the path of the bullet from an AR-15 is vastly different from a low-velocity handgun injury. The bullet from an AR-15 passes through the body like a cigarette boat traveling at maximum speed through a tiny canal. The tissue next to the bullet is elastic—moving away from the bullet like waves of water displaced by the boat—and then returns and settles back. This process is called cavitation; it leaves the displaced tissue damaged or killed. The high-velocity bullet causes a swath of tissue damage that extends several inches from its path. It does not have to actually hit an artery to damage it and cause catastrophic bleeding. Exit wounds can be the size of an orange.
With an AR-15, the shooter does not have to be particularly accurate. The victim does not have to be unlucky. If a victim takes a direct hit to the liver from an AR-15, the damage is far graver than that of a simple handgun-shot injury. Handgun injuries to the liver are generally survivable unless the bullet hits the main blood supply to the liver. An AR-15 bullet wound to the middle of the liver would cause so much bleeding that the patient would likely never make it to the trauma center to receive our care.
One of my ER colleagues was waiting nervously for his own children outside the school. While the shooting was still in progress, the first responders were gathering up victims whenever they could and carrying them outside the building. Even as a physician trained in trauma situations, there was nothing he could do at the scene to help save the victims who had been shot with the AR-15. Most of them died on the spot; they had no fighting chance at life.
As a doctor, I feel I have a duty to inform the public of what I have learned as I have observed these wounds and cared for these patients. It’s clear to me that AR-15 and other high-velocity weapons, especially when outfitted with a high-capacity magazine, have no place in a civilian’s gun cabinet. I have friends who own AR-15 rifles; they enjoy shooting them at target practice for sport and fervently defend their right to own them. But I cannot accept that their right to enjoy their hobby supersedes my right to send my own children to school, a movie theater, or a concert and to know that they are safe. Can the answer really be to subject our school children to active-shooter drills—to learn to hide under desks, turn off the lights, lock the door, and be silent—instead of addressing the root cause of the problem and passing legislation to take AR-15-style weapons out of the hands of civilians?
In the aftermath of this shooting, in the face of specific questioning, our government leaders did not want to discuss gun control even when asked directly about the issue. Senator Marco Rubio of Florida warned not to “jump to conclusions that there’s some law we could have passed that could have prevented it.” A reporter asked House Speaker Paul Ryan about gun control, and he replied, “As you know, mental health is often a big problem underlying these tragedies.” And on Tuesday, Florida’s state legislature voted against considering a ban on AR-15-type rifles, 71 to 36.
If politicians want to back comprehensive mental-health reform, I am all for it. As a medical doctor, I’ve witnessed firsthand the toll that mental-health issues take on families and on individuals themselves who have no access to satisfactory long-term mental-health care. But the president and Congress should not use this issue as an excuse to deliberately overlook the fact that the use of AR-15 rifles is the common denominator in many mass shootings.
A medical professor taught me about the dangers of drawing incorrect conclusions from data, using the example of gum chewing, smokers, and lung cancer. He said smokers may be more likely to chew gum to cover bad breath, but one cannot look at the data and decide that gum chewing causes lung cancer. It is the same type of erroneous logic that focuses on mental health after mass shootings, when banning the sale of semiautomatic rifles would be a far more effective means of preventing them.
Banning the AR-15 should not be a partisan issue. No consensus may exist on many questions of gun control, but there seems to be broad support for removing high-velocity, lethal weaponry and high-capacity magazines from the market, which would drastically reduce the incidence of mass murders. Every constitutionally guaranteed right that we are blessed to enjoy comes with responsibilities. Even our right to free speech is not limitless. Second Amendment gun rights must respect the same boundaries.
The Centers for Disease Control and Prevention is the appropriate agency to review the potential impact of banning AR-15-style rifles and high-capacity magazines on the incidence of mass shootings. The agency was effectively barred from studying gun violence as a public-health issue in 1996, by a statutory provision known as the Dickey Amendment. This provision needs to be repealed so that the CDC can study this issue and make sensible gun-policy recommendations to Congress.
The Federal Assault Weapons Ban (AWB) of 1994 included language that prohibited semiautomatic rifles such the AR-15, and also large-capacity magazines with the ability to hold more than 10 rounds. The ban was allowed to expire on September 13, 2004, after 10 years. The mass murders that have followed the ban’s lapse make clear that it must be reinstated.
On Wednesday night, Rubio said at a town-hall event hosted by CNN that it is impossible to create effective gun regulations because there are too many “loopholes,” and that a “plastic grip” can make the difference between a gun that is legal and one that is illegal. But if we can see the different impacts of high- and low-velocity rounds clinically, then the government can also draw such distinctions.
As a radiologist, I have now seen high-velocity AR-15 gunshot wounds firsthand, an experience that most radiologists in our country will never have. I pray that these are the last such wounds I have to see, and that AR-15-style weapons and high-capacity magazines are banned for use by civilians in the United States, once and for all.
Gunshot Wounds Forensic Pathology
Type of Firearm
These devices can classify into two basic categories, based on the type of firearm – namely rifled firearms and smooth-bore firearms (shotguns). A third category includes country-made firearms that use unusual projectiles and is seen more commonly in less developed countries.
Gunshot wounds can also classify depending on the muzzle velocity of the projectile and fall into low-velocity and high-velocity firearm injuries. British researchers have generally used the speed of sound in air, i.e., 1,100 feet/second (335 m/s), to classify these differences. American researchers meanwhile have used arbitrary classification, using 2,000, 2,500, or 3,000 m/s to classify firearms into low-velocity and high-velocity. These are also classified as small and large arms, respectively.
In addition to the direct effects of the projectile and accompanying components, gunshot wounds, especially of large-arms, may be accompanied by a sonic wave; this is usually not of great consequence, except when involving hollow viscera, like intestines, that could suffer disruption. The secondary effects in a gunshot wound are more severe due to a phenomenon known as temporary cavitation. These temporary forces include radial acceleration, shear, stretch, and compression and result in disruption of the tissue away from the main injury tract. They are more extensive in solid, uncompressible organs.
Entry and Exit Wound
The distance and direction of shooting also affect the characteristics of the wound, including the shape, invagination of tissue, the effects of accompanying components including flame, smoke, gas, unburnt particles, metal scraps, and grease. Gunshot wounds can produce two types of wounds, depending on the direction of travel of the projectile. These are entry wounds and exit wounds – entry wounds are generally smaller and more regular than exit wounds. Entry wounds show invagination of tissue into the wound, while exit wounds show outward beveling of tissue. The skin surrounding the entry wound will show the above characteristics, depending on the distance as described later; this includes the presence of flame burns and singeing, soiling and redding from gas, as well as tattooing from unburnt particle and metal scraps. Similarly, the presence of an abrasion rim and grease collar around the wound also indicate that it is an entry wound. (See Figure 1) However, an abrasion rim may also be present on the exit wound, where the skin is shored against a hard surface.
Exit wounds, in comparison, are larger and more irregular. They show outward beveling of the soft tissue and the margin. Entry wounds will be free of characteristics, including flame burns and singeing, soiling and redding from gas, as well as tattooing from unburnt particles and metal scraps. They do not have an abrasion rim or grease collar, except when the skin is shored against a hard surface. (See Figure 2)
Distance of Fire
Depending on the distance of fire, the wound can also classify as contact wounds – again divided into firm-contact and loose contact – near-contact or close-range wounds, mid-range or intermediate-range wounds, distant or far-range wounds, and indeterminate wounds.
Contact wounds are self-explanatory and are diagnosable by the presence of muzzle-imprint on the skin. Near-contact or close-range wounds are identifiable by the presence of flame burns and singeing of hair. Mid-range or intermediate-range wounds do not have flame burns or singeing of hair but will show the presence of smoke, gas, and unburnt particles. Distant or far-range wounds will be embedded with any accompanying components other than the lubricant forming a grease collar. Indiscriminate wounds are atypical wounds beyond the range of the weapon with an irregular shape due to yawing (changing in the axis and direction of flight of the projectile).
It is evident from the explanation above that the determination of the distance of fire is dependent on the type of firearm. Typically, small-arms, including revolvers and pistols, eject the flame for a distance of 15 cm while large arms, including most automatic 'assault' rifles, propel the flame for a distance of 30 cm. The accompanying components also demonstrate dramatic differences in the distance traveled depending on the type of weapon and can range from 15 to 30 cm for smoke and gas, 30 to 60 cm for unburnt particles and metal scraps in small arms, which may be propelled much greater distances in large arms. While these distances are arbitrary and provide a general outlook on the distance of fire, each weapon would have individual variations and, therefore, should be tested for confirmation.
In addition to the above findings, the distance of fire also affects the nature of the wound, especially in contact wounds. Contact wounds can thus divide into two different classes, firm contact and loose contact. In loose contact wounds, the gases, gunpowder, flame, and other material mostly enter the wound. However, due to the loose contact, a small portion of it may escape from the gap between the muffle and skin and may be found on the skin surrounding the injury. In the case of firm contact wounds, the nature of injuries is further dependant on the underlying tissue. In contact gunshot wounds with soft tissue underlying the injury, the injuries are similar to those caused by loosed contact, except that surrounding skin and tissue are free from flame burns, soot, tattooing, and other changes. These findings are present in the depth of the wound. Also, there is a distinct muzzle pattern around the injury.
In contact gunshot wounds with bony tissue underlying the injury, the injuries are typically called a stellate wound, where the gases exit the barrel before the projectile. As a result, the gas collides with the bone tissue, resulting in the reflection of the gases. This gas causes the expansion of subcutaneous space and pressure, which results in an explosive injury, tearing, and lacerating the skin and subcutaneous tissue, resulting in the stellate wound. Additionally, the expanding gases also cause a back-splatter of soft-tissue and blood onto the firearm and fingers.
Similarly, the wound's location on the body can affect the wound characteristics and, perhaps, more importantly, the outcome of the injury. It is abundantly evident that the involvement of a major organ or vessel can lead to life-threatening injuries. Solid organs are susceptible to more significant injuries as compared to hollow organs or elastic tissue. The location of the injury can also affect the wound characteristics by the effect of the intervening layers of clothing or other objects that can not only reduce the velocity of the projectile but also prevent the deposition of accompanying components.
Smooth-bore firearms or shotguns have a completely different profile of injuries as compared to rifled firearms. This difference is determined primarily by the type of projectiles in the shotgun. Shotgun cartridges consist of multiple projectiles that disperse a short distance from the muzzle, leading to more extensive damage. The penetrating power of each projectile is, however, reduced.
Also, the significant difference between smooth-bored weapons and rifled weapons is the projectile. While a single projectile is ejected from the muzzle of a rifled firearm, the entire cartridge is released from the smooth-bored firearm. This cartridge consists of multiple tightly packed pellets that disperse as the cartridge moves towards the target. These pellets or projectiles are secured using plastic or cardboard wads that help separate the primer and gunpowder from the projectiles while also preventing the diffusion of pressure and gas upon their burning. Smooth-bore firearms, therefore, produce injuries that also show abrasions and contusion caused by the projectiles, cartridges, and wads. Also, the injury tract may contain pieces of cardboard or plastic, called wads,
Shotguns, in general, also propel the flame for a distance of 15 cm, smoke and gas for 30 cm, unburnt particles, and metal scraps for 60 cm. The contact injuries appear similar to a rifled firearm, in both pressed and loose, as well as with underlying bone and soft tissue. In pressed or firm contact injuries, the skin may present with a double muzzle imprint from the double barrels.
In general, gunshot injuries resulting from firing a smooth-bore weapon within 30 cm presents as a circular wound with smooth or crenated margins with no satellite pellets and presence of wads in the wound tract, in addition to the effects of accompanying components, including skin burns and singeing due to the flame, soiling and redding of tissue due to gas and smoke, tattooing from unburnt powder and metal scraps.
The pellets tend to show a pattern of dispersion beyond 60 cm, which presents as nibbling of a 'rat-hole" circular wound, with minimal satellite injuries and wads, that may be present. The flame burns and singeing are absent, and also, there is minimal or absent redding of the tissue from carbon monoxide.
Beyond a distance of 1 meter, the pellets become sufficiently dispersed to demonstrate a central "rat-hole" wound with multiple satellite pellet holes, with no burning or singeing, no reddening of tissue, no soiling, no tattooing, and absence of wads in the wound tract.
Beyond a distance of 10m, the pellets are completely dispersed, seen as multiple small punctate injuries with the absence of a central wound. Similarly, none of the accompanying components reaches the injury, and their effects are not seen.
The dispersion of the pellets is extremely variable and depends on the weapon and the cartridge. This is further complicated by the practice of choking of the barrel, intentional narrowing of the muzzle, which increases the dispersion of pellets at a given range. As with rifled firearms, it is essential to test each weapon for individual variations.
Figure 1 - Entry wound of a rifled small arm (revolver) showing the abrasion collar. Note that the location of the injury was over the chest, with layers of intervening clothing, leading to loss of soiling and tattooing. Therefore, the distance in this (more...)
Figure 2 - Exit wound from a rifled small arm (revolver) showing larger injury, in comparison with the entry wound. Also, the injury is irregular in shape, with outward beveling of the margin. Used with Permission from Department of Forensic Medicine, (more...)
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Form of physical trauma sustained from the discharge of arms or munitions
|Male skull showing bullet exit wound on parietal bone, 1950s.|
|Symptoms||Pain, deformity, bleeding|
|Complications||PTSD, lead poisoning, nerve injury,wound infection, sepsis, brain damage, gangrene, disability, amputation|
|Risk factors||Illegal drug trade, ignorance of firearm safety, substance misuse including alcohol, mental health problems, firearm laws, social and economic differences|
|Prevention||Firearm safety, not being involved in crime|
|Frequency||1 million (interpersonal violence in 2015)|
A gunshot wound (GSW) is physical trauma caused by a projectile from a firearm. Damage may include bleeding, broken bones, organ damage, infection of the wound, loss of the ability to move part of the body, and in more severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include lead poisoning and post-traumatic stress disorder (PTSD).
Factors that determine rates of firearm violence vary by country. These factors may include the illegal drug trade, access to firearms, substance misuse including alcohol, mental health problems, firearm laws, and social and economic differences. Where guns are more common, altercations more often end in death.
Before management begins it should be verified the area is safe. This is followed by stopping major bleeding, then assessing and supporting the airway, breathing, and circulation. Firearm laws, particularly background checks and permit to purchase, decrease the risk of death from firearms. Safer firearm storage may decrease the risk of firearm-related deaths in children.
In 2015, about a million gunshot wounds occurred from interpersonal violence. In 2016, firearms resulted in 251,000 deaths globally, up from 209,000 in 1990. Of these deaths 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 (9%) were accidents. In the United States, guns resulted in about 40,000 deaths in 2017. Firearm-related deaths are most common in males between the ages of 20 to 24 years. Economic costs due to gunshot wounds have been estimated at US$140 billion a year in the United States.
Signs and symptoms
Trauma from a gunshot wound varies widely based on the bullet, velocity, mass, entry point, trajectory, and affected anatomy. Gunshot wounds can be particularly devastating compared to other penetrating injuries because the trajectory and fragmentation of bullets can be unpredictable after entry. Moreover, gunshot wounds typically involve a large degree of nearby tissue disruption and destruction caused by the physical effects of the projectile correlated with the bullet velocity classification.
The immediate damaging effect of a gunshot wound is typically severe bleeding with the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs. In the case of traumatic hypovolemic shock, this failure of adequate oxygen delivery is due to blood loss, as blood is the means of delivering oxygen to the body's constituent parts. Devastating effects can result when a bullet strikes a vital organ such as the heart, lungs or liver, or damages a component of the central nervous system such as the spinal cord or brain.
Common causes of death following gunshot injury include bleeding, low oxygen caused by pneumothorax, catastrophic injury to the heart and major blood vessels, and damage to the brain or central nervous system. Non-fatal gunshot wounds frequently have mild to severe long-lasting effects, typically some form of major disfigurement such as amputation because of a severe bone fracture and may cause permanent disability. A sudden blood gush may take effect immediately from a gunshot wound if a bullet directly damages larger blood vessels, especially arteries.
The degree of tissue disruption caused by a projectile is related to the cavitation the projectile creates as it passes through tissue. A bullet with sufficient energy will have a cavitation effect in addition to the penetrating track injury. As the bullet passes through the tissue, initially crushing then lacerating, the space left forms a cavity; this is called the permanent cavity. Higher-velocity bullets create a pressure wave that forces the tissues away, creating not only a permanent cavity the size of the caliber of the bullet but a temporary cavity or secondary cavity, which is often many times larger than the bullet itself. The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path. The extent of cavitation, in turn, is related to the following characteristics of the projectile:
- Kinetic energy: KE = 1/2mv2 (where m is mass and v is velocity). This helps to explain why wounds produced by projectiles of higher mass and/or higher velocity produce greater tissue disruption than projectiles of lower mass and velocity. The velocity of the bullet is a more important determinant of tissue injury. Although both mass and velocity contribute to the overall energy of the projectile, the energy is proportional to the mass while proportional to the square of its velocity. As a result, for constant velocity, if the mass is doubled, the energy is doubled; however, if the velocity of the bullet is doubled, the energy increases four times. The initial velocity of a bullet is largely dependent on the firearm. The US military commonly uses 5.56-mm bullets, which have a relatively low mass as compared with other bullets; however, the speed of these bullets is relatively fast. As a result, they produce a larger amount of kinetic energy, which is transmitted to the tissues of the target. The size of the temporary cavity is approximately proportional to the kinetic energy of the bullet and depends on the resistance of the tissue to stress.Muzzle energy, which is based on muzzle velocity, is often used for ease of comparison.
- Yaw: Handgun bullets will generally travel in a relatively straight line or make one turn if a bone is hit. Upon travel through deeper tissue, high-energy rounds may become unstable as they decelerate, and may tumble (pitch and yaw) as the energy of the projectile is absorbed, causing stretching and tearing of the surrounding tissue.
- Fragmentation: Most commonly, bullets do not fragment, and secondary damage from fragments of shattered bone is a more common complication than bullet fragments.
Gunshot wounds are classified according to the speed of the projectile using the Gustilo open fracture classification:
- Low-velocity: Less than 1,100 ft/s (340 m/s)
Low velocity wounds are typical of small caliberhandguns and display wound patterns like Gustilo Anderson Type 1 or 2 wounds
- Medium-velocity: Between 1,200 ft/s (340 m/s) and 2,000 ft/s (610 m/s)
These are more typical of shotgun blasts or higher caliber handguns like magnums. The risk of infection from these types of wounds can vary depending on the type and pattern of bullets fired as well as the distance from the firearm.
- High-velocity: Between 2,000 ft/s (610 m/s) and 3,500 ft/s (1,100 m/s)
Usually caused by powerful assault or hunting rifles and usually display wound pattern similar to Gustilo Anderson Type 3 wounds. The risk of infection is especially high due to the large area of injury and destroyed tissue.
Bullets from handguns are sometimes less than 1,000 ft/s (300 m/s) but with modern pistol loads, they usually are slightly above 1,000 ft/s (300 m/s), while bullets from most modern rifles exceed 2,500 ft/s (760 m/s). One recently developed class of firearm projectiles is the hyper-velocity bullet, such cartridges are usually either wildcats made for achieving such high speed or purpose built factory ammunition with the same goal in mind. Examples of hyper velocity cartridges include the .220 Swift, .17 Remington and .17 Mach IV cartridges. The US military commonly uses 5.56mm bullets, which have a relatively low mass as compared with other bullets (40-62 grains); however, the speed of these bullets is relatively fast (Approximately 2,800 ft/s (850 m/s), placing them in the high velocity category). As a result, they produce a larger amount of kinetic energy, which is transmitted to the tissues of the target. However, one must remember that high kinetic energy does not necessarily equate to high stopping power, as incapacitation usually results from remote wounding effects such as bleeding, rather than raw energy transfer. High energy does indeed result in more tissue disruption, which plays a role in incapacitation, but other factors such as wound size and shot placement play as big of, if not a bigger role in stopping power and thus, effectiveness. Muzzle velocity does not consider the effect of aerodynamic drag on the flight of the bullet for the sake of ease of comparison.
Medical organizations in the United States recommend a criminal background check being held before a person buys a gun and that a person who has conviction/s for crimes of violence should not be permitted to buy a gun. Safe storage of firearms is recommended, as well as better mental health care and removal of guns from those at risk of suicide. In an effort to prevent mass shootings greater regulations on guns that can rapidly fire many bullets is recommended.
Initial assessment for a gunshot wound is approached in the same way as other acute trauma using the advanced trauma life support (ATLS) protocol. These include:
- A) Airway - Assess and protect airway and potentially the cervical spine
- B) Breathing - Maintain adequate ventilation and oxygenation
- C) Circulation - Assess for and control bleeding to maintain organ perfusion including focused assessment with sonography for trauma (FAST)
- D) Disability - Perform basic neurological exam including Glasgow Coma Scale (GCS)
- E) Exposure - Expose entire body and search for any missed injuries, entry points, and exit points while maintaining body temperature
Depending on the extent of injury, management can range from urgent surgical intervention to observation. As such, any history from the scene such as gun type, shots fired, shot direction and distance, blood loss on scene, and pre-hospital vitals signs can be very helpful in directing management. Unstable people with signs of bleeding that cannot be controlled during the initial evaluation require immediate surgical exploration in the operating room. Otherwise, management protocols are generally dictated by anatomic entry point and anticipated trajectory.
A gunshot wound to the neck can be particularly dangerous because of the high number of vital anatomical structures contained within a small space. The neck contains the larynx, trachea, pharynx, esophagus, vasculature (carotid, subclavian, and vertebral arteries; jugular, brachiocephalic, and vertebral veins; thyroid vessels), and nervous system anatomy (spinal cord, cranial nerves, peripheral nerves, sympathetic chain, brachial plexus). Gunshots to the neck can thus cause severe bleeding, airway compromise, and nervous system injury.
Initial assessment of a gunshot wound to the neck involves non-probing inspection of whether the injury is a penetrating neck injury (PNI), classified by violation of the platysma muscle. If the platysma is intact, the wound is considered superficial and only requires local wound care. If the injury is a PNI, surgery should be consulted immediately while the case is being managed. Of note, wounds should not be explored on the field or in the emergency department given the risk of exacerbating the wound.
Due to the advances in diagnostic imaging, management of PNI has been shifting from a "zone-based" approach, which uses anatomical site of injury to guide decisions, to a "no-zone" approach which uses a symptom-based algorithm. The no-zone approach uses a hard signs and imaging system to guide next steps. Hard signs include airway compromise, unresponsive shock, diminished pulses, uncontrolled bleeding, expanding hematoma, bruits/thrill, air bubbling from wound or extensive subcutaneous air, stridor/hoarseness, neurological deficits. If any hard signs are present, immediate surgical exploration and repair is pursued alongside airway and bleeding control. If there are no hard signs, the person receives a multi-detector CT angiography for better diagnosis. A directed angiography or endoscopy may be warranted in a high-risk trajectory for the gunshot. A positive finding on CT leads to operative exploration. If negative, the person may be observed with local wound care.
Important anatomy in the chest includes the chest wall, ribs, spine, spinal cord, intercostal neurovascular bundles, lungs, bronchi, heart, aorta, major vessels, esophagus, thoracic duct, and diaphragm. Gunshots to the chest can thus cause severe bleeding (hemothorax), respiratory compromise (pneumothorax, hemothorax, pulmonary contusion, tracheobronchial injury), cardiac injury (pericardial tamponade), esophageal injury, and nervous system injury.
Initial workup as outlined in the Workup section is particularly important with gunshot wounds to the chest because of the high risk for direct injury to the lungs, heart, and major vessels. Important notes for the initial workup specific for chest injuries are as follows. In people with pericardial tamponade or tension pneumothorax, the chest should be evacuated or decompressed if possible prior to attempting tracheal intubation because the positive pressure ventilation can cause hypotention or cardiovascular collapse. Those with signs of a tension pneumothorax (asymmetric breathing, unstable blood flow, respiratory distress) should immediately receive a chest tube (> French 36) or needle decompression if chest tube placement is delayed. FAST exam should include extended views into the chest to evaluate for hemopericardium, pneumothorax, hemothorax, and peritoneal fluid.
Those with cardiac tamponade, uncontrolled bleeding, or a persistent air leak from a chest tube all require surgery. Cardiac tamponade can be identified on FAST exam. Blood loss warranting surgery is 1–1.5 L of immediate chest tube drainage or ongoing bleeding of 200-300 mL/hr. Persistent air leak is suggestive of tracheobronchial injury which will not heal without surgical intervention. Depending on the severity of the person's condition and if cardiac arrest is recent or imminent, the person may require surgical intervention in the emergency department, otherwise known as an emergency department thoracotomy (EDT).
However, not all gunshot to the chest require surgery. Asymptomatic people with a normal chest X-ray can be observed with a repeat exam and imaging after 6 hours to ensure no delayed development of pneumothorax or hemothorax. If a person only has a pneumothorax or hemothorax, a chest tube is usually sufficient for management unless there is large volume bleeding or persistent air leak as noted above. Additional imaging after initial chest X-ray and ultrasound can be useful in guiding next steps for stable people. Common imaging modalities include chest CT, formal echocardiography, angiography, esophagoscopy, esophagography, and bronchoscopy depending on the signs and symptoms.
Important anatomy in the abdomen includes the stomach, small bowel, colon, liver, spleen, pancreas, kidneys, spine, diaphragm, descending aorta, and other abdominal vessels and nerves. Gunshots to the abdomen can thus cause severe bleeding, release of bowel contents, peritonitis, organ rupture, respiratory compromise, and neurological deficits.
The most important initial evaluation of a gunshot wound to the abdomen is whether there is uncontrolled bleeding, inflammation of the peritoneum, or spillage of bowel contents. If any of these are present, the person should be transferred immediately to the operating room for laparotomy. If it is difficult to evaluate for those indications because the person is unresponsive or incomprehensible, it is up to the surgeon's discretion whether to pursue laparotomy, exploratory laparoscopy, or alternative investigative tools.
Although all people with abdominal gunshot wounds were taken to the operating room in the past, practice has shifted in recent years with the advances in imaging to non-operative approaches in more stable people. If the person's vital signs are stable without indication for immediate surgery, imaging is done to determine the extent of injury.Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectory and fragmentation. However, the best and preferred mode of imaging is high-resolution multi-detector CT (MDCT) with IV, oral, and sometimes rectal contrast. Severity of injury found on imaging will determine whether the surgeon takes an operative or close observational approach.
Diagnostic peritoneal lavage (DPL) has become largely obsolete with the advances in MDCT, with use limited to centers without access to CT to guide requirement for urgent transfer for operation.
The four main components of extremities are bones, vessels, nerves, and soft tissues. Gunshot wounds can thus cause severe bleeding, fractures, nerve deficits, and soft tissue damage. The Mangled Extremity Severity Score (MESS) is used to classify the severity of injury and evaluates for severity of skeletal and/or soft tissue injury, limb ischemia, shock, and age. Depending on the extent of injury, management can range from superficial wound care to limb amputation.
Vital sign stability and vascular assessment are the most important determinants of management in extremity injuries. As with other traumatic cases, those with uncontrolled bleeding require immediate surgical intervention. If surgical intervention is not readily available and direct pressure is insufficient to control bleeding, tourniquets or direct clamping of visible vessels may be used temporarily to slow active bleeding. People with hard signs of vascular injury also require immediate surgical intervention. Hard signs include active bleeding, expanding or pulsatile hematoma, bruit/thrill, absent distal pulses and signs of extremity ischemia.
For stable people without hard signs of vascular injury, an injured extremity index (IEI) should be calculated by comparing the blood pressure in the injured limb compared to an uninjured limb in order to further evaluate for potential vascular injury. If the IEI or clinical signs are suggestive of vascular injury, the person may undergo surgery or receive further imaging including CT angiography or conventional arteriography.
In addition to vascular management, people must be evaluated for bone, soft tissue, and nerve injury. Plain films can be used for fractures alongside CTs for soft tissue assessment. Fractures must be debrided and stabilized, nerves repaired when possible, and soft tissue debrided and covered. This process can often require multiple procedures over time depending on the severity of injury.
Further information: List of countries by firearm-related death rate
In 2015, about a million gunshot wounds occurred from interpersonal violence. Firearms, globally in 2016, resulted in 251,000 deaths up from 209,000 in 1990. Of these deaths 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 were accidents. Firearm related deaths are most common in males between the ages of 20 to 24 years.
The countries with the greatest number of deaths from firearms are Brazil, United States, Mexico, Colombia, Venezuela, Guatemala and South Africa which make up just over half the total. In the United States in 2015 about half of the 44,000 people who died by suicide did so with a gun.
As of 2016, the countries with the highest rates of gun violence per capita were El Salvador, Venezuela, and Guatemala with 40.3, 34.8, and 26.8 violent gun deaths per 100,000 people respectively. The countries with the lowest rates of were Singapore, Japan, and South Korea with 0.03, 0.04, and 0.05 violent gun deaths per 100,000 people respectively.
In 2016, about 893 people died due to gunshot wounds in Canada (2.1 per 100,000). About 80% were suicides, 12% were assaults, and 4% percent were an accident.
Further information: Gun violence in the United States
In 2017, there were 39,773 deaths in the United States as a result gunshot wounds. Of these 60% were suicides, 37% were homicides, 1.4% were by law enforcement, 1.2% were accidents, and 0.9% were from an unknown cause. This is up from 37,200 deaths in 2016 due to a gunshot wound (10.6 per 100,000). With respect to those that pertain to interpersonal violence, it had the 31st highest rate in the world with 3.85 deaths per 100,000 people in 2016. The majority of all homicides and suicides are firearm-related, and the majority of firearm-related deaths are the result of murder and suicide. When sorted by GDP, however, the United States has a much higher violent gun death rate compared to other developed countries, with over 10 times the number of firearms assault deaths than the next four highest GDP countries combined. Gunshot violence is the third most costly cause of injury and the fourth most expensive form of hospitalization in the United States.
Until the 1880s, the standard practice for treating a gunshot wound called for physicians to insert their unsterilized fingers into the wound to probe and locate the path of the bullet. Standard surgical theory such as opening abdominal cavities to repair gunshot wounds,germ theory, and Joseph Lister's technique for antiseptic surgery using diluted carbolic acid, had not yet been accepted as standard practice. For example, sixteen doctors attended to President James A. Garfield after he was shot in 1881, and most probed the wound with their fingers or dirty instruments. Historians agree that massive infection was a significant factor in Garfield's death.
At almost the same time, in Tombstone, Arizona Territory, on 13 July 1881, George E. Goodfellow performed the first laparotomy to treat an abdominal gunshot wound.: M-9 Goodfellow pioneered the use of sterile techniques in treating gunshot wounds, washing the person's wound and his hands with lye soap or whisky, and his patient, unlike the President, recovered. He became America's leading authority on gunshot wounds and is credited as the United States' first civilian trauma surgeon.
Mid-nineteenth-century handguns such as the Colt revolvers used during the American Civil War had muzzle velocities of just 230–260 m/s and their powder and ball predecessors had velocities of 167 m/s or less. Unlike today's high-velocity bullets, nineteenth-century balls produced almost little or no cavitation and, being slower moving, they were liable to lodge in unusual locations at odds with their trajectory.
Wilhelm Röntgen's discovery of X-rays in 1895 led to the use of radiographs to locate bullets in wounded soldiers.
Survival rates for gunshot wounds improved among US military personnel during the Korean and Vietnam Wars, due in part to helicopter evacuation, along with improvements in resuscitation and battlefield medicine. Similar improvements were seen in US trauma practices during the Iraq War. Some military trauma care practices are disseminated by citizen soldiers who return to civilian practice. One such practice is to transfer major trauma cases to an operating theater as soon as possible, to stop internal bleeding. Within the United States, the survival rate for gunshot wounds has increased, leading to apparent declines in the gun death rate in states that have stable rates of gunshot hospitalizations.
Research into gunshot wounds in the USA is hampered by lack of funding. Federal-funded research into firearm injury, epidemiology, violence, and prevention is minimal.
- Stab wound, an equivalent penetrating injury caused by a bladed weapon or any other sharp objects.
- Blast injury, an injury that may present similar dangers to a gunshot wound.
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A Trauma Surgeon Talks About Wound Ballistics and Stopping Power
Dr. Sydney Vail is a trauma surgeon and one of the nation's leading authorities on tactical medicine and the care of gunshot victims. His articles—"9mm Vs. .40 Caliber" and "Stopping Power: Myths, Legends, and Realities"—are some of the most popular and most controversial in the history of POLICE Magazine and PoliceMag.com.
Vail, who has studied the performance of handgun ammunition in both the gunshot wound patients he has operated on and in the works of researchers like Dr. Martin Fackler, is a strong believer that size of ammunition used in a handgun has much less effect on stopping a threat than shot placement.
In "Stopping Power" he wrote: "I believe the definition of stopping power should be a particular ammunition's effectiveness to render a person unable to offer resistance or remain a threat to the officer, an intended victim, or self.
"So how does ammunition accomplish this? You have two options. You can use a really large round at very high velocity like the 30mm cannon rounds from an Apache helicopter's M230 Chain Gun, which produces substantial kinetic energy, or you can place your shot where it has the most effect. Obviously, shot placement is the only realistic option for a law enforcement officer."
Vail's argument that the stopping power of handgun ammunition is not based on caliber has elicited howls of protest from members of the firearms community who are devotees of particular cartridges, especially the .45 ACP. Vail says he enjoys the debate and he reads the comments on his articles, but he stands by his conclusions about ammo performance based on his experience as a scientist, a surgeon, a shooter, and a tactical medical provider.
The following is an excerpt of a longer interview covering tactical medicince, tourniquet use by officers, and wound ballistics that will be published in the January 2018 Police Magazine and on PoliceMag.com.
POLICE: What's the highest number of rounds you've seen shot into a person who's survived?
Vail: The largest number of bullet wounds has been 22. Some were just entry, some were entry/exits. But 22, I think, was my maximum number. It's not uncommon for me to get 8 or 10 or 12 wounds and people survive.
I got involved in wound ballistics and what it really took to stop a threat during residency in Philadelphia because I had a friend on the police force who lost his job for use of excessive force by shooting somebody, I think it was, 18 times, and I always thought, maybe he needed to shoot that person 18 times to stop the threat.
As a surgeon, I saw what bullets don't do to the human body, meaning they don't kill it, they don't just stop it...which is why I wrote that article about stopping power; it's really a myth. I know that the human body can tolerate many gunshots and still function so that the person is still a threat to the police officer. So I make it known that I am willing to help defend a police officer who is accused of excessive force based on the number of shots fired. If it's a clean shoot, I'm happy to review it. If I can agree with them after that review, then I'll be there to testify for them.
POLICE: Is there really a significant difference in terms of wound ballistics between a 9mm, .40, and .45?
Vail: Other than the size of the ballistic projectile, nope. Because unless you hit something vital, it doesn't matter what you hit them with. You could hit them with a .45 in the shoulder, they're gonna survive. You hit them with a 9mm in the shoulder, they're gonna survive. You hit them with a .22 in the brain they could die. So, stopping a threat really does not come down to caliber, it is shot placement.
Handguns are lousy stoppers; it doesn't matter the caliber, they are just not great at stopping threats. Because of the ballistics profile and the amount of energy that a rifle round carries with it and dumps into the body, a rifle is a much better instrument to stop a threat.
POLICE: Can a significant temporary wound cavity be produced by a handgun bullet?
Vail: You really don't get much of a temporary cavity with a handgun. It's there, but it's minimal as compared to a rifle round and, you know, I think that's where ballistic gel [has value]. It's not my favorite substance in the world, but it demonstrates that if you fire a rifle round into it, the temporary cavity is extremely large. You don't really get much damage from the hydrostatic "pressure" of tissues ripping from a handgun.
Police: Can agencies learn anything about their ammo through gelatin testing?
Vail: Yes. You can look at certain characteristics of the ammo: expansion and depth of penetration. But that's all. And you're comparing those two things in gelatin. How those relate to the human body is where I argue you're getting misinformation because the bullets will not act the same in the human body as they act in gelatin.
POLICE: What ammo do you carry in your personal defense pistol?
Vail: Well, for my SWAT team I carry a .45 with Speer Gold Dots issued. Personally I generally carry my 9mm most often because of its capacity (loaded with Federal HST rounds).
David Griffith has been editor of POLICE Magazine since December 2001. He brings more than 25 years of experience on magazines and newspapers to POLICE. A Maggie award-winning journalist, his byline has appeared on hundreds of articles in POLICE and other national magazines.View Bio
David Griffith has been editor of POLICE Magazine since December 2001. He brings more than 25 years of experience on magazines and newspapers to POLICE. A Maggie award-winning journalist, his byline has appeared on hundreds of articles in POLICE and other national magazines.View Bio
Gunshot wounds 9mm
As a result, he passed out altogether and I sat down in my place. Our employee was telling something, everyone was laughing and I leaned back in my chair sipping a martini. At the end of. The evening, everyone had a good meal and Yuri, being apparently the only able-bodied man, beckoned me to the shower.How Far Will a 9mm Kill?
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At that moment, when he still chose a member from me, and sperm flowed from my ass, I experienced a wild orgasm. So I haven't finished yet. And it was a good reward for my broken point. Subsequently, I could only play the role of a victim - a whore who. Knows that it is better not to rock the boat when her holes are brutally raped.