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KGS 04-21-2006 12:06 AM

Getting shot in the stomach
 
Once again, this is for a story I'm writing. I want to describe a medically accurate gunshot wound, preferably in the lower torso, whereby the character:

(1) Nearly bleeds to death, due to a severed artery (like in the movie "M*A*S*H": "We've got a gusher!")
(2) Undergoes surgery, where he wakes up and can feel every bit of pain, but can't call out to anyone, so he wills his heart to stop until the doctors "shock" him and that puts him under again...oh okay, this part is pure Creative License. ;)
(3) Recovers quickly enough to be mobile within 2 weeks, and eventually able to perform strenuous tasks like hiking 5 miles, climbing over fences & crawling through gutters, making stabbing motions with a knife...yeah, it's that kind of story.

If a five-mile hike causes him to reinjure himself, that's fine.

At first I was thinking a "flesh wound" that doesn't pierce the abdominal wall, but that doesn't sound gooshy enough...how about a bullet to the spleen? Or the liver?

outlierrn 04-21-2006 12:46 AM

spleens not bad, it can bleed like stink, but it's relatively small and non-essential so your recovery time could plausibly be quicker than a major artery or the liver. I'm an ER nurse so post op course is not my area, two weeks maybe pretty optimistic. nitpick/ we don't shock a stopped heart, only a fibrillating one, ie disorganized movement/nitpick

picunurse 04-21-2006 03:09 AM

KGS, you again?! :D
Gut shots are very painful, often have very long recovery times, because of the massive infections they are prone to. When what belongs inside the gut, wanders into better neighborhoods, everything can and often does, hitch a ride in the proverbial hand basket.
The gut shot itself can cause major bleeding, without involving other organs. The mesentery is the covering that holds the intestine together. It is extrordinarily vascular. A shot ripping through the mesentery and the bowel is a bloody, stinky, life threatening emergency. The Mesenteric arteries come directly off the Aorta.
BTW, a severed artery in the abdomen would be, if not fatal, life changing. Better the artey is damaged, and repairable.

As far as the waking up thing, often, with big abdominal trauma, the patient would remain intubated after surgery. Likely, he would be given a paralytic agent to prevent movement, which could cause more injury. Paralytic agents are not sedative, nor do they relieve pain. If a sloppy anesthesiologist were to neglect to order sufficient analgesia and sedation, your patient would experience massive pain and be unable to tell anyone. He it's very doubtful his heart would stop, although, pain can cause multiple symptoms. It actually will increase heart rate to an alarming level. It can cause blood pressure spikes or it may cause the blood pressure to drop to such a profound level as to required the support of vasopressors.
Any untoward symptoms would be "discovered" by a nurse, never a doctor. The nurse does an assessment at least once an hour. In very critical patients it could be as often as every 5-10 minutes.
The surgeon visits once, maybe twice a day. He does an abreviated assessment, because he relies on the nurse to be alert to any changes. In most ICUs if a patient has a terminal event, the nurses start the rescusitation. The doctor runs the show once he's on scene, but, prompt action by the nursing staff save the life.
The ICU nursing staff would never allow a chemically paralyzed patient to go unmedicated. I have, however, recieved patients from anesthesia that have only paralytic recorded on the flow chart. ( In the hospitals where I've seen that happen the anesthesiologist has been immediately suspended, one was fired, one was not.)
The only action that would be taken would be to immediately give a dose of narcotic and sedation intravenously. They act nearly instantly.

Two weeks is a very optimistic recovery time. They invariably have stubborn peritonitis, so the surgeon often wouldn't even close the wound for 3or 4 weeks. When it finally is closed, they need to be watched it be sure the infection is truly clear.

As far are the extent of recovery, if the person was young and in good health prior to being wounded, they should make a full recovery. But realisticly it would take 3 weeks to many months.
Once the skin of the abdomen is healed, normal exercise shouldn't cause a problem.

Being shot or stabbed in the liver or spleen would be serious, but a surgical repair would bring him back to 100% fairly fast. He wouldn't be intubated, paralyzed, or even in the ICU after surgery.
A damaged spleen would be, as outlierrn said, removed. It's not ideal, but life without a spleen is livable.
Livers, on the other hand, have to be repaired. Life just ain't worth livin' without it. Or even possible. The liver will regenerate to some degree. Controlling bleeding is often the biggest problem. A severe liver lac can require upwards of 40 units of blood during surgery. Once repaired, the person may or may not be in the ICU. Just the fact of receiving that much banked blood might buy a ticket. The person would likely not be intubated, or paralyzed. They also have a hightened possibility of breaking loose a clot that can cause stroke, heart attack, or other eschemic injury.

gabriela 04-21-2006 06:23 AM

Hey, picunurse. I just want to say I have always enjoyed your replies.

I'm no great shakes on the "recovery" mode (my patients are always stable after my procedures, aside from a slow ongoing decomposition), but I sure can give you a lot of places a person can get shot that are life-threatening.

How quickly after the shot does he/she receive medical care? Moments? Because when I was a surgery intern, we occasionally saved someone who was aorta-shot, by clamping it off. Never any inferior vena cava shots - the blood would just keep puddling up from the depths, there was nothing you could clamp. Course a rescued aorta-shot person would likely not bounce back in two weeks.

But that suggests you could go through any medium-sized artery and not die so long as the ambulance gets there inside of two minutes. How about the external iliac artery? Or, crossing the inguinal ligament, the femoral artery, close enough to the peritoneal cavity to bleed inside rather than outside? You could get either of those with a tangential shot through the abdominal wall that would almost look like a flesh wound. If the shot missed the guts, I would think two weeks would be a reasonable recovery time.

Or how about a shot that hits the mesentery tracking right to left, goes below the colon and stomach and just above the pancreas (I know it sounds miraculous, but I see weirder things all the time), and hits the splenic artery, just before heading out beneath the twelfth rib? You could either leave the bullet in the body, or have a nice little exit on the back. Big operation (you do realize most of the pain your character is experiencing will be from the operation - the surgeons' cuts. GSW itself not terribly painful), probable splenectomy, clamp it off for a quick repair. If no pancreatitis, two weeks not impossible for bounceback.

Just remember, after splenectomy, big risk of pneumonia from encapsulated organisms.

Do you need any descriptions for a gunshot wound entrance or exit?

BrightSmite 04-21-2006 06:54 AM

I remember seeing an ex-mobster being interviewd a couple of years ago. He said there was a hit on a guy who was eating a big bowl of pasta with is wife in his apartment. The hitman came in and killed the guy.

One of the shots hit him in the stomach. He said the pasta spewed out of the bullet hole.


anyway

Melkor28 04-21-2006 09:00 AM

A few years ago I had a sigmoidoscopy*( bowl rescetion).; I was given general anethisa, an epidural, and was not intubated. While they where moving me off the operating table after the surgery, I woke up. They gave me another epidural before sending me to my room. When I woke up, while being moved, I could not talk due to all the drugs, and it was very "foggy", I was like "Mmmm!...MMMmmm!"
I have always had a high restience to anethesiacs, my mom too. You could angle your story along these lines.

I relize I was not intubated because I was preped for surgery, and it was not an emergency. May be you could have the bullet clip the colon, lots of blood, not bad enough for same day surgery; have the surgery a couple of days later. Or something like that.



* not sure if I have the right medical term.

picunurse 04-21-2006 10:13 AM

Quote:

Originally Posted by Melkor28
A few years ago I had a sigmoidoscopy*( bowl rescetion).; I was given general anethisa, an epidural, and was not intubated. While they where moving me off the operating table after the surgery, I woke up. They gave me another epidural before sending me to my room. When I woke up, while being moved, I could not talk due to all the drugs, and it was very "foggy", I was like "Mmmm!...MMMmmm!"
I have always had a high restience to anethesiacs, my mom too. You could angle your story along these lines.

I relize I was not intubated because I was preped for surgery, and it was not an emergency. May be you could have the bullet clip the colon, lots of blood, not bad enough for same day surgery; have the surgery a couple of days later. Or something like that.



* not sure if I have the right medical term.

A sigmoidoscopy is a test similar to a colonoscopy, it isn't as long and they use a rigid tube rather than the flexible fiberoptic. You may have been sedated for that.
A bowel resection is an operation, where in, part of the intestine is removed and the ends sewn back together. That can be done as a minimal invasive surgery, as long as they're not looking for cancer. In that case, you might not be intubated. You wouldn't be under general anesthesia, either.
For elective surgeries, the endotracheal tube is inserted after onset of anesthesia, and ideally, removed before reversal.
So most people may not even know they were intubated. The chance of something going terribly wrong while under general anesthesia are too great to not intubate.

gabriela, thank you for the compliment. I could tell you some "war" stories about surprising saves with major bleeding, but I've promised not to go over the gross line on the board. I've been known to make grown men cry. :cool: (or worse)

I will give one example. Not a gunshot wound, but a motorcycle accident. The young man was riding at a high rate, (by his own admission) at midnight on the four lane that runs past the hospital I worked in at the time. Another vehicle hit him and left the scene. His right leg was disarticulated at the hip. The femoral artery was torn, but not completely separated. That type of breach holds the vessel open, unlike a total severing, when the vessel will actually snap back into the surrounding tissue, bringing some hemostasis.
The accident happened 20 feet from the hospital entrance. One of the medic units going back out after a drop off found him, maybe seconds after it happened. Not only did he live, we were able to reattach the leg. He got 85 units of blood in OR, and other blood products too numerous to count. The trauma team had to stay in the OR to give blood products while 3 surgeons worked on him. I was from the ICU, the other trauma nurse was from ER and the two trauma docs were from the ER as well.
We were in the OR for 14 hours. There was a mix up, the next shift didn't know they were supposed to relieve us, so we had no choice but to stay.
He was in the ICU for three weeks. He had a completely uneventful ICU stay. He went home, and a week later, threw a clot, and died at home from a stroke.

Everyone else:
Please tell me if that was over the line. I don't want to frighten anyone or make anyone feel ill.


You're a pathologist, correct?
(I hope I can get this right. I heard it years ago...)
An internist knows everything and does nothing.
A surgeon Knows nothing and does everything.
A pathologist knows everything, and does everything, but a day too late. :D

KGS 04-21-2006 10:28 AM

Thanks for the replies! Once again, the SDMB is an invaluable wealth of information.

Quote:

Originally Posted by gabriela
How quickly after the shot does he/she receive medical care?

The shooting takes place at a high school, so there *should* be someone immediately available with at least basic first aid. EMTs arrive in 3-5 minutes. The victim is taken by LifeFlight to a metro area trauma center (anyone know a likely place in the San Fernando Valley?) -- exsanguination is a big problem, and his vitals are basically in "crash" mode before he even reaches the hospital.

(I'm basing this part on an actual shooting from several years ago. The victim's condition was described as "extremely critical" and "moment-to-moment" all afternoon long. Yes, he did survive...the doctors called him "a real fighter.")

Quote:

Do you need any descriptions for a gunshot wound entrance or exit?
Yes, the writer should always know these things, whether it makes the story or not. ;) I haven't given much thought about the exit wound, or if there will even be one...exit wounds tend to be messy, don't they?

Quote:

Originally Posted by picunurse
A severe liver lac can require upwards of 40 units of blood during surgery. Once repaired, the person may or may not be in the ICU. Just the fact of receiving that much banked blood might buy a ticket. The person would likely not be intubated, or paralyzed.

I'm a bit confused as to why intubation/ICU would be used for some injuries but not others. Would the patient be intubated before surgery, if his vitals were in "crash" mode? If so, how long would the intubation last?

Quote:

They also have a hightened possibility of breaking loose a clot that can cause stroke, heart attack, or other prior eschemic injury.
AHA...I like this one! You see, the character suffers what appears to be a petit mal seizure in the presence of a doctor who knows of his gunshot injury. (This takes place 1-2 months later, still working on the time frame.) However, the REAL cause is supernatural...which means, I can make up any symptoms I want! :D I'm thinking cold/clammy skin, labored pulse, dilated pupils...what other symptoms would possibly indicate a stroke?

drachillix 04-21-2006 10:54 AM

Quote:

Originally Posted by KGS
I'm thinking cold/clammy skin, labored pulse, dilated pupils...what other symptoms would possibly indicate a stroke?

Also look for not just dialated pupils but pupils dialated different amounts.

Hemiparesis (sp) - partial paralysis usually of one side of the body or ther other

Pulsus differansus - Expansion of difference between systolic and diastolic blood pressure ex first vitals show BP 130 over 80, 5 min later 135 over 75, 5 min later 140 over 70.

Be careful on your terminology and physiology..having someone in a medical background give it a once over before you call it good to avoid any major rolleyes from the medical community. Terms like stable but serious, extremely critical condition, etc are news shorthand for "we have no fucking clue and couldn't pronounce it right if we did know what was, but its gonna leave a mark"

Qadgop the Mercotan 04-21-2006 11:21 AM

Quote:

Originally Posted by picunurse
A sigmoidoscopy is a test similar to a colonoscopy, it isn't as long and they use a rigid tube rather than the flexible fiberoptic. You may have been sedated for that.

Most sigmoidoscopies these days are done with a flexible fiberoptic sigmoidoscope. I haven't seen a rigid one done since the early 1980's.

glee 04-21-2006 11:40 AM

I have no medical qualifications. :(

But I have had a sigmoidoscopy recently! :cool:

It was expertly done.

The admitting nurse (excuse me if I get the titles wrong) explained that they would basically insert a camera up my bottom to check the bowel for any problems.
I wouldn't need an anaesthetic and it wouldn't take long.

I was invited to lie down on a table and pick a side to lie on. I could either watch the camera monitor or not. :dubious:
I decided not to watch. I confess to being influenced because the consultant had asked my permission for a student to observe the procedure. This turned out to be a young gorgeous blonde female, who was opposite the monitor...

Anyway the tube went in and then they explained that they would pump air in to help keep my passage open. This felt strange. :confused:

Finally the consultant pronounced me all clear and left me in the hands of the student (so to speak). I was just deciding how to ask her for a date when she mentioned that removing the tube would release the pressure.
I promptly farted for well over a minute. :eek:

(No, I didn't ask her out...)

Melkor28 04-21-2006 12:05 PM

I had 10 " of my largintestin removed. Diverticulitus, preferatied colon due to an infection in the little sac things; resulting in a larg absess. Absess removed, bowl recection, with a bag for 4 mounths. Thank god that was reversed. If I was intubated, they never told me. They explain the whole procdure; but I guess they concentrait on the surgery and stuff; they did tell me they where doing an epidural, thhey should have mentioned the intubation.

Clothahump 04-21-2006 12:29 PM

Quote:

Originally Posted by picunurse
I will give one example. Not a gunshot wound, but a motorcycle accident. The young man was riding at a high rate, (by his own admission) at midnight on the four lane that runs past the hospital I worked in at the time. Another vehicle hit him and left the scene. His right leg was disarticulated at the hip. The femoral artery was torn, but not completely separated. That type of breach holds the vessel open, unlike a total severing, when the vessel will actually snap back into the surrounding tissue, bringing some hemostasis.
The accident happened 20 feet from the hospital entrance. One of the medic units going back out after a drop off found him, maybe seconds after it happened. Not only did he live, we were able to reattach the leg. He got 85 units of blood in OR, and other blood products too numerous to count. The trauma team had to stay in the OR to give blood products while 3 surgeons worked on him. I was from the ICU, the other trauma nurse was from ER and the two trauma docs were from the ER as well.
We were in the OR for 14 hours. There was a mix up, the next shift didn't know they were supposed to relieve us, so we had no choice but to stay.
He was in the ICU for three weeks. He had a completely uneventful ICU stay. He went home, and a week later, threw a clot, and died at home from a stroke.

Everyone else:
Please tell me if that was over the line. I don't want to frighten anyone or make anyone feel ill.

Not over. Rather mild and quite interesting, IMNSHO.

outlierrn 04-21-2006 12:49 PM

lets see:

Intubation is one of the first things to do with a "crashing" pt, even if their problem isn't primarily respitory. Post op intubation can last for days or weeks. In a previously healthy pt it depends a lot on the surgery. It's not unusual to chemically paralyze a pt post op if a chest or belly wound hasn't been closed due to swelling or contamination, movement could be fatal, such a pt will be intubated and on a ventilator.

stroke: acute mental status changes, slurred speech, facial droop on one side with weakness of one or both extremities on the same side are the BIG symtoms we see in the ER. I have seen a strokes cause siezures and generalyed changes instead of the usu one side or the other, but that's less common. It all about location, whatever portion of the brain is blood deprived, that's the function that will be lost. There are two types of stroke, occlusive ie blood clot, or hemorrhagic ie ruptured vessel, both present the same, but are treated differently. Basically there's nothing we can do for a bleeder except wait and see, maybe bring their blood pressure down if they are hypertensive. Surgery to evacuate blood from the skull is possible, but that's after a massive event and your character is not going to get back up and fight. With a clot, you can have a dramatic event and a dramatic recovery, at least it's medically possible, even if it doesn't work out that way IRL as often as on TV. Rapid administration of clot dissolving drugs is the key here.

Picunurse,
I'll match you story for story anytime you want, let's party :)

gabriela 04-21-2006 01:12 PM

Quote:

Originally Posted by picunurse

gabriela, thank you for the compliment. I could tell you some "war" stories about surprising saves with major bleeding, but I've promised not to go over the gross line on the board. I've been known to make grown men cry. :cool: (or worse)
... He got 85 units of blood in OR... He had a completely uneventful ICU stay. He went home, and a week later, threw a clot, and died at home from a stroke.

Everyone else:
Please tell me if that was over the line. I don't want to frighten anyone or make anyone feel ill.

Picunurse, that was not over the line. Well, at least my line. Well, um, that is to say, I lost track of the normal human line long ago.

I find war stories fascinating, and hope to tempt you across the line to more of them.

Quote:

Originally Posted by picunurse
You're a pathologist, correct?

I'm a forensic pathologist, and I think I have successfully pushed the line a foot or six farther out in only a hundred or so posts.

Why don't we start a thread entitled "War Stories Known to Make Grown Men Cry", and alternate until somebody reports crying?

bwahahaha...
and they dared threaten me with the goat...

gabriela 04-21-2006 01:13 PM

Quote:

Originally Posted by outlierrn
lets see:

Picunurse,
I'll match you story for story anytime you want, let's party :)

Ooh ooh ooh. Ooh ooh ooh. Can I play?

gabriela 04-21-2006 01:23 PM

Quote:

Originally Posted by KGS
Thanks for the replies! Once again, the SDMB is an invaluable wealth of information.

The shooting takes place at a high school, so there *should* be someone immediately available with at least basic first aid. EMTs arrive in 3-5 minutes. The victim is taken by LifeFlight to a metro area trauma center (anyone know a likely place in the San Fernando Valley?) -- exsanguination is a big problem, and his vitals are basically in "crash" mode before he even reaches the hospital.

Those're bad. You have to be young, and a fighter, to come back from those.


Quote:

Originally Posted by KGS
Yes, the writer should always know these things, whether it makes the story or not. ;) I haven't given much thought about the exit wound, or if there will even be one...exit wounds tend to be messy, don't they?

Entrances are a quarter inch wide, look like neat, punched out ovals with a continuous trickle of blood from them, and have a thin dark ring at the edge of the raw flesh (the "abrasion ring"). Exits are a quarter inch to a half inch wide, look like slits or torn slits with v-shaped ends, and have a thinner trickle of blood from them, and no abrasion ring.

The exit is only messy when you are shot with a rifle or other high velocity gun. Those exits are the classic ones which most people think of - the famous exits that are larger than the entrances. They are not typical. By no means. At all. The exit from the average handgun looks a bit like what you would get if you were playing around with a broom handle inside a pup tent, and you accidentally poked it through the top of the tent. A slit with tears at the ends.

Plus the trickle of blood, of course.

Quote:

Originally Posted by KGS
I'm a bit confused as to why intubation/ICU would be used for some injuries but not others. Would the patient be intubated before surgery, if his vitals were in "crash" mode? If so, how long would the intubation last?

Intubation is used whenever we can't count on the patient to handle his breathing himself. Absolutely, anyone who's crashing will be intubated. Anyone with a flesh wound will not be intubated. In betwen, judgement call, erring on the side of intubate.

If you have elective surgery, you will be put under and then intubated. There is a danger moment right between "going under" and "intubated", which all anesthesia personnel I have ever watched handle with professional smoothness. You are extubated before you wake up. You are hoarse afterwards for a day, and may not know why.

If you have elective or emergency surgery, and you are too ill afterwards to be relied on to breathe on your own, you will remain intubated, awake or not, until you can be trusted to breathe without help. You may find this process very difficult and annoying. Picunurse, have you had many people who were awake and alert but ventilator dependent, who tore out their own ETT and died from it? I will never forget one of mine... I gave her my Sunday paper to read in the ICU and my last sight of her was reading it intently in the morning, then off to the morgue in the afternoon. Brr.

Of course that was from before I was a pathologist.

Daithi Lacha 04-21-2006 01:35 PM

Along the same lines, any truth to the notion that a gut-shot leads reflexively to a bowel dump?

gabriela 04-21-2006 01:40 PM

Quote:

Originally Posted by Daithi Lacha
Along the same lines, any truth to the notion that a gut-shot leads reflexively to a bowel dump?

Death leads reflexively to a bowel dump.

The cases I have seen strongly suggest to me that all peristalsis ceases completely the moment the bowels are injured. Ugh, that week-old pastrami, in half-chewed bites, still motionless in his stomach a week after he was shot in the belly.

Makes sense, I remember from my surgery training that even handling the bowel made it go insulted and stop processing for a few days.

Picunurse? Ever seen gutshot lead to bowel dumping? Hunters?

drachillix 04-21-2006 02:52 PM

Quote:

Originally Posted by gabriela
Picunurse? Ever seen gutshot lead to bowel dumping? Hunters?

I have but it was not via normal channels. Shotgun slug left to right through the abdominal cavity pretty thoroughly eviscerating him in the process, wasn't much of his intestines left inside. Guy didn't make it.

Fish 04-21-2006 03:46 PM

I work in a radiology clinic I just read the reports, I'm no doctor and it just so happens I have a report handy to consult on an abdominal GSW.

I don't know what your story is going to require, but here's some medical-sounding stuff you can peruse, and use as necessary. I'm trusting that picnurse will add or correct as needed.

As picnurse said, the patient will probably be intubated. In particular, that's called an endotracheal or ET tube. The staff may also say that patient is on a ventilator, or vented; if the patient has to be transported in a hurry somewhere, he might be bagged (that is, those hand-held squeezey bags operated by a respiratory therapist). This tube might be taken out right after surgery if the patient is breathing on his own.

This patient also had a feeding tube, also called an NG or nasogastric (from the nose to the stomach) tube. It probably means the patient came in unconscious. That tube probably wouldn't come out right after abdominal surgery, as the bowels don't like to be handled by surgeons; it takes them a few days to start working properly again.

The patient will almost certainly also have a vascular line, particularly for infusing units of blood, but also for adding meds. This particular patient with a right upper quadrant (RUQ) GSW has a vascular access in his right subclavian vein, but they might instead put in a CVC (central venous catheter) in his right or left internal jugular vein, or a PICC line (peripherally inserted CvC or just "peripheral line") in one of his arms.

This patient also has RUQ abdominal drains, presumably as a result of bleeding.

Even if they know the patient had a GSW and where, they'll likely take an X-ray to see where the bullet is, and if it fragmented. To get the right flavor of doctory talk, let me imagine for you what the X-ray will read like:

Code:

Imaginary left lower quadrant X-ray of an
imaginary patient with GSW to the spleen

SUPINE ABDOMEN XR, AP VIEW, AT 1115 HOURS
There are radiopaque metal fragments in the LLQ
consistent with known bullet wound.  Possible fracture
in left ninth rib.  Detail is obscured by underlying
backboard.  The spleen is inadequately visualized.

AP view stands for anteroposterior, or "from the front to the back."

KGS 04-21-2006 05:54 PM

How common is it for a bullet to fragment/ricochet when striking soft tissue? (We're talking small caliber here, .38 or below.)

Also, how painful/uncomfortable is it to have a breathing tube removed? I'd imagine it's pretty nasty, like yanking your lungs out of your throat...or do they sedate the patient first?

St. Urho 04-21-2006 06:29 PM

Quote:

Originally Posted by KGS
The shooting takes place at a high school, so there *should* be someone immediately available with at least basic first aid. EMTs arrive in 3-5 minutes. The victim is taken by LifeFlight to a metro area trauma center (anyone know a likely place in the San Fernando Valley?) -- exsanguination is a big problem, and his vitals are basically in "crash" mode before he even reaches the hospital.

Unless this is taking place in an outlying part of the metro area (and I'm not familiar with the valley) odds are your patient wouldn't go by air medical. It takes too long. Around here (Denver metro) we can usually get the patient to a trauma center before a helicopter would. The exceptions would be if we are up in the foothills or have too many patients to handle.

If it helps, here's what would probably happen on scene. PD arrives first. The fire and medic units would stage until the PD clears them into the scene. The medics would get a quick report from the officers on scene and then load-and-go. Your pt would get 2 large-bore IVs en route. Depending on his mental status, he might get intubated or get analgesics. He'd go lights and sirens to the hospital.

Oh, and the last GSW to the abdomen we ran, the patient had bowel contents oozing out of the entrance wound. No spontaneous BM, though.

St. Urho
Paramedic

picunurse 04-21-2006 07:51 PM

Quote:

Originally Posted by Qadgop the Mercotan
Most sigmoidoscopies these days are done with a flexible fiberoptic sigmoidoscope. I haven't seen a rigid one done since the early 1980's.

Thank you, I should have guessed that. Luckily for me, I haven't "seen" one since the early '70s. :D

KGS, Often, a smaller caliber shot will result in more internal damage than a larger on. The reason is the higher velocity projectile will simply pass through everything. Slower, smaller ones tend to bounce around. Say, one is shot in the lower abdomen, the slower bullet, after passing through the large intestine, could bounce off the pelvis or spine, go through a kidney or bladder, or be deflected upward and even hit a lung, liver, or any other vital organ. It can be even worse in the chest, where a bullet will dance around hitting ribs, until it loses momentum.

Let's try to organize this a bit.
1. Gun shot, fall down bleed.

2. Bystander rescurers arrive. First aid. Call 911

3. Pros arrive. Here we have some judgement calls. Stay long enough to put in a line to replace volume and intubate in the field, or use a bag/valve/mask, and scoop and run.
Transport by ground or wait for Airlift. The only time Airlift is preferrable is if the time saved is worth the time wasted. If the incident happens a 15 minute drive from ACLS help, then you drive. If it happens 20 miles from the nearest ER, during rush hour the 45 minutes to an hour waiting for Airlift might be worth it. Remember, Airlift, Lifeflight, what ever your air transport service is called, is only faster once they get to you. When they are notified they have to gather their gear, go from quarters to the ship, which has to warm up before it can takeoff. At your end, it has to have a place to land. Sometimes they have to land a fair distance away, so the first responders load the patient into the bus and drive to the ship, off load from the ambulance, reload into the helicopter. Then Airlift has to make sure the patient is safe to fly and they are safe to fly with him. There isn't a lot of room inside. Often the patient's feet are next to the pilot's head. If the patient is thrashing around from pain, or confusion the nurse or medic will paralyze them and intubate, just for safety. It doesn't do any good to takeoff quickly and have the pilot kicked unconscious and crash.
Also, even though a level one trauma center is preferable, with major, uncontrollable bleeding, closer is better. Any ER is a better environment to control it than the school parking lot. Formost, they have access to banked blood, They can get unmatched
O-neg in a matter of minutes. They can transfer after the patient is stable.

4. In the ER, whether a level one trauma center or Bob's ER, certain things will happen. If the patient isn't intubated, they will be, blood loss causes hypotension, hypotension causes unconsciousness, unconsciousness causes loss of automatic airway protection, loss of airway protection, often causes death. Also, hypoventilation (not breathing enough) along with hypotension, means the cells are being deprived of the oxygen they need.
Even though the endotracheal tube has a cuff ( a circumferential balloon on the tube to prevent liquid from running into the lungs around the tube) a Nasogastric tube will also be placed to prevent vomiting. At least two large bore IVs, or a multilumin central line, will be placed to give blood, supportive medications and fluids rapidly. If they are at their final destination, (ie) a level one trauma center, an arterial line, to monitor blood pressure and to do serial lab work will also go in.
If the bleeding can't be controlled in ER, they would go directly to OR, where all these things would be done, while the surgeon works on stopping the bleeding. There could be upwards of a dozen people working on the patient at the same time.

5. All of the things being done to stop the bleeding and to save the life have their own consequences. Banked blood has an anticoagulant in it, after every 4 units, a reversing agent needs to be given. If it can't be given because the blood is being dumped in so fast, then bleeding from other places may start. Since banked blood has some of the components removed, those components have to be given as well. Platelets, and plasma are the two most important ones. They contain the important clotting factors that have been diluted in the patient.

Blood is cold, a major drop in body temp can cause arrhythmias. fluids, including blood are often given on a Level A rapid infuser. Which delivers large volumes and warms the fluid going in.
If the injury was in the chest, the blood could be collected in a special container and be reinfused, but abdominal wounds run too much risk of contamination.

6. As I mentioned, the blood loss causes hypotension. The hypotension is actually more complicated. It's really hypovolimic shock. If fluids and blood could be replaced fast enough, it would reverse itself once the tank was full again. Unfortunately, that usually doesn't happen. One thing happening, is the tissues aren't getting all the oxygen they require, oxygen deprived cells die. That is brain cells, heart cells, kidney cells, liver cells. if enough die, function stops. Even with the breathing tube, and 100% oxygen, the cells can't get enough if the blood pressure isn't high enough to push the blood to those organs. Eventually hypovolimic shock becomes cardiogenic shock, which is infinitely harder to reverse. So, we introduce pressors. Dopamine, Epinephrine, and last resort, Norepinephrine, brand name, Levophed, nicknamed "Leave-em-dead".
(Here, I find myself wanting to explain the way pressors work. That would take way too much time. Just trust me on this one, unless there's a pharmacist out there willing to explain Alpha and Beta effects of pressors)
The stress of the injury, the blood loss and shock causes the body to use it's catecholamines faster than it can produce them. Dopamine is a precursor to epinephrine. It raises blood pressure with the least negative impact and the end organs. If it dosen't work, or stops working Epinephrine can be added. Epi has more vasoconstrictive properties, and can cause too much stress on an already compromised heart. Norepinephrine is a last resort, because its vasoconstrictive power can compromise even a healthy heart.

Ok, I just looked this over, and I think I may be going off on a tangent. Tell me if any of this is helpful, or if it just sounds like babbling.




gabriela & outlierrn, one of you start it, I'll participate. :D

Fish 04-21-2006 08:07 PM

I've never been awake when my ET tubes are removed. I couldn't say on the pain thing. It's my understanding that it probably wouldn't be comfortable, too.

I'd guess from this hypothetical situation your patient wouldn't be intubated until surgery, and the tube removed later that day (or the next). If the patient is breathing on his own and his sats look good (that's oxygen saturation, which they monitor with a little plastic clip that goes on your finger and connects to a device with a two-digit red LED display: for your story, good sats are like 97-99) and his lungs are clear, he probably doesn't need the vent any longer.

Having an NG tube removed, on the other hand, isn't all that bad. There's a tugging sensation on your face and you feel like the Elephant Who Got His Trunk on the banks of the great, grey-green greasy Limpopo River like your nose is being stretched like taffy and pulled off. When it's out, there's a very brief taste, and a lingering sour smell (stomach acid?) for a few minutes. No big deal.

Fish 04-21-2006 08:30 PM

Great answer, picnurse. Let me unpack some of it for KGS.

double-lumen catheter a vascular access with a Y at the end, so it can be hooked to two different things at once (like to an IV with a medicinal drip, and simultaneously to an infuser infusing blood). There are also triple-lumen catheters. (I don't like to nitpick spelling, but it is for a story.)

hypotension

vasoconstrictor

hypovolimic shock

cardiogenic shock

pressors

catecholamines

KGS 04-21-2006 08:32 PM

picunurse, this is fascinating stuff.

What would be a typical recovery scenario? I'm figuring, he awakens late that night or the next day, tubes are removed (except the IV's, I guess) and spends 2-3 days in the hospital before going home, 2-3 weeks before he can resume normal activity. Does this sound accurate?

What types of complications would be expected? (There aren't any in the story, but obviously the doctors would warn him of what to look for.) Would he be given any medication as an outpatient, like antibiotics to prevent infection?

What sort of physical limitations -- esp. sports, bike riding, etc. -- would be imposed on him, and for how long? How likely is it that strenuous exercise, 3 weeks after the shooting, would cause him to reinjure himself?

picunurse 04-21-2006 10:24 PM

Quote:

Originally Posted by Fish
Great answer, picnurse. Let me unpack some of it for KGS.

double-lumen catheter a vascular access with a Y at the end, so it can be hooked to two different things at once (like to an IV with a medicinal drip, and simultaneously to an infuser infusing blood). There are also triple-lumen catheters. (I don't like to nitpick spelling, but it is for a story.)

hypotension

vasoconstrictor

hypovolimic shock

cardiogenic shock

pressors

catecholamines

Thanks, for both the spelling and the explanatory links, sometimes I just get carried away. :rolleyes:

KGS, well, for the scene I just described, he'd be critically ill for several days. As I said, massive blood loss causes lots of problems. Are we assuming the shot missed his bowel completely? Any injury that dumps bowel contents causes peritonitis This site shows step by step the course. Warning! Graphic wound pictures!
If you're really going to be medically accurate, you're either going to have to give him a month in the hospital with a week of that in ICU with all its attendant inconviences, including intubation, unconsciousness and paralysis. Otherwise, he needs to have a less complicated injury.
A through and through right side chest shot could cause a lot of bleeding , and require a chest tube for a few days, but is easier to treat quickly enough that he wouldn't have the collateral damage from contamination. Evenif one of the vena cavae was nicked, as long as he got into surgery quickly, he could avoid the complications from the profound blood loss. They'd repair the vascular injury, close any chest wounds, and re-expand his lung by means of a chest tube. That would stay in for a few days. He could wake up from that by that night.
You might want to explore the TraumaBank web site, for lots of great information and :dubious: graphic pictures...Warning! Graphic wound pictures!

Restrictions after abdominal trauma or, for that matter, surgery, would be to avoid anything that might re-open the skin wound or the internal wounds. I doubt you'll want to include the routine of stool softeners and bulk laxatives needed, right? :rolleyes: No sit-ups for a while. No martial arts, getting kicked in the belly wouldn't be ideal, and some of the moves pull at the abdomen.
Restrictions after the chest trauma would involve not lifting over five pounds, not raising arms over the head, anything that could put strain on the vascular repair. The restrictions for either would be for about a month, sometimes more, sometimes less.

outlierrn 04-21-2006 10:29 PM

Quote:

Originally Posted by KGS
picunurse, this is fascinating stuff.

What would be a typical recovery scenario? I'm figuring, he awakens late that night or the next day, tubes are removed (except the IV's, I guess) and spends 2-3 days in the hospital before going home, 2-3 weeks before he can resume normal activity. Does this sound accurate?

What types of complications would be expected? (There aren't any in the story, but obviously the doctors would warn him of what to look for.) Would he be given any medication as an outpatient, like antibiotics to prevent infection?

What sort of physical limitations -- esp. sports, bike riding, etc. -- would be imposed on him, and for how long? How likely is it that strenuous exercise, 3 weeks after the shooting, would cause him to reinjure himself?


With a GSW to the abdomen we'd fire big gun antibiotics first and ask questions later.

Recovery time can vary widely, depends on the damage of the initial wound, and what the surgeon has to do to fix it. They may have to enlarge the wound, or take an approach through the abdominal wall that will take some time to heal. If your character needs to fight, you need to think of the core muscles of the abdomen and back. Any crunches, twisting of the torso, or kicking will bring these into play. A more or less straight shot that lodges in the spleen would give you life threatening blood loss, let you bring out all the toys so far described, and still be able to bounce back. Anything involving peritonitis (shit gets out of the GI track and causes infection), or major surgery involving the abd muscles will lay your pt up for awhile.

When it comes to activity, a lot of the time we tell people to let their pain be their guide, but not to be stupid, if your player is going to be doing some Van Damage in 2-3 weeks, he's likely to pay a price in pain, weakness and may start bleeding again, though probably not severely. He also runs the risk of adhesions and other poor healing problems that can give pain for life.

St. Urho 04-21-2006 10:44 PM

Quote:

Originally Posted by picunurse
3. Pros arrive. Here we have some judgement calls. Stay long enough to put in a line to replace volume and intubate in the field, or use a bag/valve/mask, and scoop and run.
Transport by ground or wait for Airlift. The only time Airlift is preferrable is if the time saved is worth the time wasted. If the incident happens a 15 minute drive from ACLS help, then you drive. If it happens 20 miles from the nearest ER, during rush hour the 45 minutes to an hour waiting for Airlift might be worth it. Remember, Airlift, Lifeflight, what ever your air transport service is called, is only faster once they get to you.

Ideally, the IV lines and ET tube would be placed en route to the hospital. Here's what the blood administration sets we carry look like.

To add to what picunurse said, when we're deciding whether or not to order a chopper, we usually figure 12-15 minutes to have our dispatch call their dispatch and to get them in the air. Add flight time to that, time to get the patient in the bird, and anything they need to do prior to takeoff and your talking easily 30+ minutes before the patient's en route to the trauma center.

brossa 04-21-2006 11:42 PM

I'm afraid that if you want your hero back up and fighting in two weeks, s/he will need a lesser injury, like a wound to an extremity.

Essentially all penetrating wounds that are associated with massive blood loss and shock are going to require disturbingly large incisions for exploration and repair. Patients who are really badly off get 'damage control' surgery, in which only the really really bad things are treated (active arterial or major venous bleeding), while 'lesser' injuries like bowel trauma, coagulopathic bleeding, fractures, etc. are 'packed off' with lots of gauze or towels (!). The patient is taken, still under anesthesia, to the ICU where resuscitation with blood, plasma, antibiotics, pressors, and sundry treatments is continued until the victim is healthy enough to go back to the OR to have their injuries reassessed.

The conventional wisdom is that surgical incisions take six weeks to reach about 85-90% of their eventual strength; it can take up to two years for the scar to remodel and reach its final strength. In the presence of contamination or infection, wound closure can be delayed for months. If your hero is up and around two weeks after major surgery, they could easily tear open the wound with strenuous activity.

You can go with a flesh wound that clips a medium-sized artery and results in significant blood loss and shock but does not require thoracic or abdominal surgery for a repair. I would suggest a gunshot that creases the skull and rips up a big flap of scalp. Your hero can have some degree of skull/brain injury (best if kept minor, like a concussion or minor skull fracture) and can bleed like stink from the scalp wound. I've seen otherwise healthy young people bleed to the point of dangerous shock from big scalp lacerations. The good news is that the hero can get resuscitated, stapled back together, and be up and about in two weeks. Of course, you can have the lingering effects of the head injury to play around with...

Are you more attached to the location of the wound or to the short recovery time?

Fish 04-22-2006 12:51 AM

Quote:

Originally Posted by outlierrn
Recovery time can vary widely, depends on the damage of the initial wound, and what the surgeon has to do to fix it.

The patient I was discussing earlier (RUQ GSW) was still in inpatient care getting regular radiological checkups at least 10 days after the initial ER visit. (I can't tell you his condition, mostly because I only see his radiological signs, and I never actually see the patient personally, but daily X-rays are usually a sign that they're not sure you're out of the woods yet.)

There are times when a GSW can be addressed without invasive surgery. In the radiological reports I read, I have seen a GSW-nicked femoral vein repaired as a non-invasive intracatheter procedure (that is, they stick a very thin flexible catheter into a vein and circumnavigate the vascular system until they get to the spot, and repair it with whatever toys they happen to have).

Bear in mind this was a shotgun GSW to the lower back/buttocks/upper thigh, not to the abdominal cavity. That should have a much much reduced recovery time than the theoretical 6-8 weeks for a LLQ GSW.

edwino 04-22-2006 01:06 AM

Quote:

Originally Posted by gabriela
Ooh ooh ooh. Ooh ooh ooh. Can I play?

I can go too. If you want to start a war stories thread, I got some good ones. We can have categories -- disgusting, depressing, bizarre.

edwino 04-22-2006 01:17 AM

To address the OP,

I think that 2 weeks is stretching it a bit, but have you considered a chest wound instead of an abdominal wound? The person may not have to bleed out, but could have instead a tension pneumothorax (a "sucking chest wound") that can cause shock instead by reducing preload to the heart. This can cause the heart to stop and the patient to require shocking and the like.

If no major structures were involved (for instance the bullet passed through a lung and didn't hit any arteries or big bronchi), a chest tube may be the only real treatment required. If there is no significant air leak, the chest tube could be removed in a week or so, and the patient could spend another few days on the floor.

If the heart did stop, though, chances are that the patient would end up with a thoracotomy along with the chest tube. You could integrate your surgery thing (point #2). Just be aware that if the patient needs any kind of chest repair (stitching up arteries, bronchi, internal cardiac massage, etc.), the recovery time would go up accordingly.

picunurse 04-22-2006 02:36 AM

Quote:

Originally Posted by edwino
To address the OP,

I think that 2 weeks is stretching it a bit, but have you considered a chest wound instead of an abdominal wound? The person may not have to bleed out, but could have instead a tension pneumothorax (a "sucking chest wound") that can cause shock instead by reducing preload to the heart. This can cause the heart to stop and the patient to require shocking and the like.

If no major structures were involved (for instance the bullet passed through a lung and didn't hit any arteries or big bronchi), a chest tube may be the only real treatment required. If there is no significant air leak, the chest tube could be removed in a week or so, and the patient could spend another few days on the floor.

If the heart did stop, though, chances are that the patient would end up with a thoracotomy along with the chest tube. You could integrate your surgery thing (point #2). Just be aware that if the patient needs any kind of chest repair (stitching up arteries, bronchi, internal cardiac massage, etc.), the recovery time would go up accordingly.

Defibrillation will do no good in the case of a tension pneumothorax.
The physiology: Air enters the chest via the chest wound. The wound doesn't allow the air to escape, so, with every attempt at a breath more air is pulled into the plural space surrounding the lung, thus collapsing the lung, eventually causing it to shift to the uninjured side, and collapsing that lung as well. As more and more air is trapped all of the structures in the chest are squeezed. Finally, the heart, while still having normal electrical conduction, is physically unable to move. It can't push blood around. No amount of shock is going to help. The only way to sucessfully restart the heart is to decompress the chest cavity by putting in a chest tube to water-seal suction.
The term for this is EMD or ElectroMechanical Dissociation.
To be honest, when this happens in the field, there is a strong likelihood of death. From the first rush of air into the chest to death is less than 5 minutes, without intervention.
If there is someone knowledgeable on scene, covering the wound with a rigid, non-porous dressing can prevent further air from entering the chest, to buy time. A credit card works. The risk of infection is out weighed by the alternative.

devilsknew 04-22-2006 02:46 AM

My Brother explained it as getting punched. He sat down and waited for the ambulance in shock. 2 cm. to the right and it would have nicked a major artery His Kidney was shredded as well as a wide swath of intestine. Point blank range .38 special. There is the recovery and a temporary colostomy.

devilsknew 04-22-2006 02:54 AM

Changing a colostomy bag stays with you. My Brother has also experienced bloodclots that have nearly killed him. The trial was witness imtimidation and a sham. Foley was let off with a light sentence because of his status as an FBI informant. He went on to kill an entire family exucution style, after 18 months in prison, a single shot to the head each. An entire family killed and disposed in their septic tank.

devilsknew 04-22-2006 03:06 AM

If it's any help for ennui and explanation. He never felt pain. Just percussive hydroshock. No pain. Just shock. Then immediate surgery. They saved his life.

KGS 04-22-2006 03:47 AM

Quote:

Originally Posted by brossa
Are you more attached to the location of the wound or to the short recovery time?

Location, definitely.

Here's what happens: Shots ring out, bodies hit the ground. Our hero stands frozen, mouth agape, horrified at what just happened. As the chaos dies down, he steps forward to render aid...and his legs buckle instantly. He looks down and sees for the first time, he's standing in a pool of his own blood, and the blood is "fountaining" out of him. (Ok, "fountaining" may be CL.) He loses consciousness within minutes, from shock and/or blood loss.

Obviously, this rules out any sort of head, shoulder, or arm injury...and I think a chest wound would be very hard to ignore. ;) (Besides, in a separate novel, I just wrote about a gunshot wound to the chest -- I tend to shoot my characters a lot, don't I??) Hmm...maybe the upper thigh would work? But then we lose the "Waking Up During Surgery O MY GOD I CAN FEEL EVERYTHING" scene...

It doesn't have to be 100% medically accurate, but it does have to be plausible. Basically, I'm striving to write something that medical professionals will read and, at worst, think: "Hmm, that's a stretch, but whatever," as opposed to: "Uh-uh. NO way. NEVER happen."

The hospital time can be stretched up to a month, if needed. But the long hike must happen within 2-3 weeks of leaving the hospital, the story requires it.

So far, a shot to the spleen (with no bowel injury) seems to have Max Bloody + Min Recovery, so let's go with that. :)

picunurse 04-22-2006 04:21 AM

Sounds like that's best bet. Best of luck. :D

gabriela 04-22-2006 05:40 AM

Quote:

Originally Posted by edwino
I can go too. If you want to start a war stories thread, I got some good ones. We can have categories -- disgusting, depressing, bizarre.

What if all my stories fit in all three?
OK, not depressing.
Wait. Maybe to an outsider they'd be depressing.

One of you start it. I'm hung over and I have my shodan test later in the morning.

outlierrn 04-22-2006 10:04 AM

Quote:

Originally Posted by gabriela
What if all my stories fit in all three?
OK, not depressing.
Wait. Maybe to an outsider they'd be depressing.

One of you start it. I'm hung over and I have my shodan test later in the morning.


ok, so I'm thinking MPSIMS?

picunurse 04-22-2006 10:28 AM

Quote:

Originally Posted by outlierrn
ok, so I'm thinking MPSIMS?

So, where is it? I checked over in MPSIMS, nothing yet. Make it good. :D

KGS 04-22-2006 08:39 PM

You guys are talking about this thread, right?

Ok, I've written the chapter, and I think it works. However, I'm a little hazy as to the precise side effects of recovering from massive blood loss. So I made stuff up (as all writers do, lol) about how his body chemistry's totally out of whack, and he suffers hot flashes/cold chills occasionally, and also has a minor pulmonary embolism which is painful, but doesn't require surgery. Also, how his 3-week hospital stay is mostly for prevention, watching for signs of infection and/or blood clotting. Thank God he's got a good HMO. :D

Any other details I should be aware of?

brossa 04-22-2006 10:53 PM

If he had a symptomatic PE while in the hospital, it'll be likely that he'll be on blood thinners (coumadin or low molecular weight heparin) for at least a few months afterward. If he threw the clot early enough that anticoagulation was contraindicated due to the risk of postop bleeding, he may have had a wire basket filter placed in his vena cava if clots were identified in his legs.


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