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  #1  
Old 05-03-2009, 08:53 PM
Ranchoth Ranchoth is online now
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Gunshot wounds—when, medically, is it better to leave a bullet in?

nneed aswnr fast

Just kidding. But seriously; in most works of fiction, one of the first orders of business in treating a gunshot wound is to dig out the bullet (assuming the bullet is still in the body, natch). Real life, of course, tends to be more complicated—President Garfield's eventually fatal gunshot wound is now thought to have been survivable, except for his doctors' constant probing to try and find the bullet; and I remember seeing a documentary (and the X-Ray) of a man who'd unknowingly shot in the head (!), the bullet traveling through his brain to lodge in the other side of his skull (!), where the doctors decided not to try and remove it.

So, generally—and I realize how wildly this could vary from patient to patient and from injury to injury—when would you just leave the slug in?
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  #2  
Old 05-03-2009, 09:01 PM
Crafter_Man Crafter_Man is offline
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The wife of a buddy of mine has a 9 mm bullet in her arm. Got hit by a ricochet at the shooting range.

Her doctor said it would be best to just leave it in there, as trying to remove it may cause localized nerve damage.
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  #3  
Old 05-03-2009, 09:07 PM
ToeJam ToeJam is offline
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Pretty much you leave it in if there's minimal risk of long term issues, as opposed to the problems of cutting it open, surgical risks of infections or such (if it's been in there for a while), or the patient is in too critical of a condition to risk another surgery like that.
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  #4  
Old 05-03-2009, 09:07 PM
Q.E.D. Q.E.D. is offline
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Generally, you'd leave it in if attempting to remove it would be likely to do more harm. It really is as simple as that.
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  #5  
Old 05-03-2009, 09:08 PM
wevets wevets is offline
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I'd say the first order of business is to stop the bleeding and treat for shock. Getting the bullet out must be why so many supporting characters die in the movies.

Getting the souvenir out is considerably lower on the list, and I'd wager doctors won't do it unless they know where the bullet is first - requiring X-rays.
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  #6  
Old 05-03-2009, 09:22 PM
Chief Pedant Chief Pedant is offline
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Most bullet wounds to body cavities are explored. If, in the process of exploration, the slug is found, then it is removed. Such removal is typically incidental, and for the most part there isn't much focus on actually finding the slug. Obviously, it's common to find it since what you are exploring is the path of the bullet. However the primary focus is on injured tissue.

For bullets not entering a cavity (chest or abdomen), efforts are directed at assessing vasculature and nerves. Without evidence of injury to those structures, bullets can usually be left alone.

Consider also shotgun wounds, which are fairly common. In those cases dozens of pellets are embedded in soft tissue, and for the most part they are left alone.

Bullets which penetrate the skull are usually removed in the course of evaluating and treating the associated trauma to the brain.

Modern imaging lets us identify with a fair degree of precision exactly where a bullet is located, so in the rare event that the final resting place is deemed to be problematic, specific exploration to "dig out the bullet" can be undertaken. I do not know why Westerns and the like make such an event of digging out the bullet (or arrowhead, for that matter). By themselves they are not usually much of an issue and even when made of lead are not felt to be a source of any systemic toxicity. There seems to be a notion that foreign objects "make their way" to vital organs, but for most objects--certainly blunt ones--this is not the case. It does happen, of course, but it's not the typical course.

Last edited by Chief Pedant; 05-03-2009 at 09:25 PM..
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  #7  
Old 05-03-2009, 09:33 PM
Crafter_Man Crafter_Man is offline
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Originally Posted by Crafter_Man View Post
The wife of a buddy of mine has a 9 mm bullet in her arm. Got hit by a ricochet at the shooting range.

Her doctor said it would be best to just leave it in there, as trying to remove it may cause localized nerve damage.
I also asked her if she was concerned about lead leaching from the bullet. She said the doctor said it was a non-issue. Even though the bullet is FMJ, isn't the base of the bullet not plated?
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  #8  
Old 05-03-2009, 09:40 PM
Q.E.D. Q.E.D. is offline
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True, but metallic lead isn't very water-soluble.
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  #9  
Old 05-04-2009, 12:07 AM
Stranger On A Train Stranger On A Train is offline
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Also it is good to leave it in place when you are a world-dominating villain who has been shot in the head with a bullet which is migrating through your brain and will eventually kill you but makes you stronger as it goes on.

I learned this from a Bond film. I also learned that nuclear physicists look like Denise Richards.

Stranger
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  #10  
Old 05-04-2009, 01:47 AM
aruvqan aruvqan is offline
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I have a friend with a piece of shrapnel lodged near his left optic nerve, if they try to remove it he will probably lose sight in that eye. They opted to leave it in place. It has been there for about 10 years now ...
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  #11  
Old 05-04-2009, 01:48 AM
Loach Loach is offline
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I remember one episode of Trauma when a doctor had to remind one of the patients that it was in his best interest to let people know he already had a couple of bullets in him whenever he is brought into the ER for future gunshot wounds. They spent a lot of wasted time trying to find wounds that weren't there because of what showed up on the X-ray.
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  #12  
Old 05-04-2009, 05:15 AM
Henrichek Henrichek is online now
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So what happens with the bullet if it is left in the body? Doesn't the body try to expel the foreign object with some nasty inflammation?
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  #13  
Old 05-04-2009, 05:56 AM
Chief Pedant Chief Pedant is offline
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Originally Posted by Henrichek View Post
So what happens with the bullet if it is left in the body? Doesn't the body try to expel the foreign object with some nasty inflammation?
Metal shards of all types are fairly inert. The body will wall them off with a surrounding layer of connective tissue and for the most part they will stay in place. There are some occasions when they move--"migrate" in medical-speak--but not very often. Infection and inflammation are not a problem for the most part if it's just metal. Cloth and wood are examples of foreign bodies that do harbor bacteria and can result in inflammation. These sorts of more porous materials are much more difficult for the immune system to sterilize. Not only do bacteria which were on the original porous material have a place to hide, so do bacteria circulating around the bloodstream (we all get the occasional bacteria that gets loose in the blood and floats around awhile before it's cleared out). Porous foreign bodies provide a nidus for circulating bacteria to hide and multiply, and even courses of antibiotics have a hard time getting to them (bone can sometimes present a similar problem).

Ordinary bullets are fairly sterile to begin with and seldom have deep unreachable crevices, so they don't get infected. An embedded torn piece of clothing or the tip of a wooden arrow would be an example of foreign bodies that would be problematic (from an infection standpoint) if not removed.

Thousands of asymptomatic soldiers walk around with a great deal of metal in their bodies.
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  #14  
Old 05-04-2009, 06:09 AM
Chief Pedant Chief Pedant is offline
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Originally Posted by Crafter_Man View Post
I also asked her if she was concerned about lead leaching from the bullet. She said the doctor said it was a non-issue. Even though the bullet is FMJ, isn't the base of the bullet not plated?
Systemic lead toxicity is seldom a problem. When the lead happens to end up in a part of the body where it's exposed to fluids that can leach out the lead, there have been reports of systemic lead toxicity. See, for example: http://www.springerlink.com/content/...ext.pdf?page=1

This is unusual enough to be reportable, and when one considers the number of folks who didn't have a problem, it's reasonable to say it's a non-issue. For almost all final resting places, the lead will get walled off with connective tissue and not leach into the rest of the body. In the example I cited, the intraarticular (inside the joint space) destination created an exception to the general rule b/c the lead was constantly bathed in fluid from the joint, and the weight-bearing nature of the hip joint ground up the lead a bit. In addition, the hip joint where the fragment was located in the first patient probably degenerated as the patient aged, and helped grind off small fragments which just made the problem worse. For most of his life, the patient experienced no symptoms and only became systemically toxic many decades after his original injury.

Last edited by Chief Pedant; 05-04-2009 at 06:10 AM..
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  #15  
Old 05-04-2009, 06:22 AM
Henrichek Henrichek is online now
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Originally Posted by Chief Pedant View Post
Metal shards of all types are fairly inert. The body will wall them off with a surrounding layer of connective tissue and for the most part they will stay in place. There are some occasions when they move--"migrate" in medical-speak--but not very often. Infection and inflammation are not a problem for the most part if it's just metal. Cloth and wood are examples of foreign bodies that do harbor bacteria and can result in inflammation.

[...]
Initially I thought the body would react the same way as to a wooden splinter (which I have experienced), but now I understand the difference.

Thanks!
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  #16  
Old 05-04-2009, 07:37 AM
Qadgop the Mercotan Qadgop the Mercotan is online now
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My patient clientele (prison inmates) tend to extrude bullets at a pretty steady rate. At least 2 or 3 times a year one presents with an old bullet rising to the surface, trying to break out through the skin!

One guy didn't even remember being shot.........
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  #17  
Old 05-04-2009, 10:49 AM
Chief Pedant Chief Pedant is offline
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Originally Posted by Qadgop the Mercotan View Post
My patient clientele (prison inmates) tend to extrude bullets at a pretty steady rate. At least 2 or 3 times a year one presents with an old bullet rising to the surface, trying to break out through the skin!

One guy didn't even remember being shot.........
Is it fair to say these are typically sterile migrations--e.g. long-standing, non-inflamed, perhaps granulomatous inclusions slowly making their way to a subcutaneous location--versus, perhaps--actively infected tracts where the foreign body is the nidus of an ongoing indolent infection? I think a number of people might think the process is like a festering deep splinter as opposed to something more like a marble gradually working its way to the surface...
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  #18  
Old 05-04-2009, 10:57 AM
Dag Otto Dag Otto is offline
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Originally Posted by Chief Pedant View Post
An embedded torn piece of clothing or the tip of a wooden arrow would be an example of foreign bodies that would be problematic (from an infection standpoint) if not removed.
Do you know how common it is that pieces of clothing are carried into the wound cavity?
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  #19  
Old 05-04-2009, 01:33 PM
MonkeyMensch MonkeyMensch is online now
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A datum point:

When I went in for bunion surgery the x-rays showed a BB lodged at the base of my right index toe. I vaguely remember some drunken college BB gun-play (we wore sunglasses!) but I thought the wound was on my big toe. It's shallow and palpaple but I never knew it was there until I saw the pics.

I asked my doc if he was going to make an incision to free it while he was performing the op. He asked, "Does it hurt?" I answered no and he said, "Well, then let's just leave it alone, shall we?"

I now refer to it as my Alien Implant.

Last edited by MonkeyMensch; 05-04-2009 at 01:37 PM..
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  #20  
Old 05-04-2009, 02:20 PM
Chief Pedant Chief Pedant is offline
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Originally Posted by Dag Otto View Post
Do you know how common it is that pieces of clothing are carried into the wound cavity?
I don't; sorry. There are hundreds of interesting articles written about penetrating trauma and retained foreign bodies, though. Perhaps better Googling than mine will pull up just what you are looking for. Despite the fact that it's unusual in general for retained metal projectiles to be a problem, there are some very interesting reports of various retained foreign bodies gone wrong, so to speak.
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  #21  
Old 05-04-2009, 02:53 PM
Shot From Guns Shot From Guns is offline
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Originally Posted by Ranchoth View Post
President Garfield's eventually fatal gunshot wound is now thought to have been survivable, except for his doctors' constant probing to try and find the bullet
IIRC, Garfield's situation isn't perfectly applicable to this particular discussion, as it wasn't the probing itself so much as the fact that it was being done with unsterilized fingers.
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  #22  
Old 05-04-2009, 07:37 PM
Qadgop the Mercotan Qadgop the Mercotan is online now
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Originally Posted by Chief Pedant View Post
Is it fair to say these are typically sterile migrations--
Yep. Only saw one that really looked infected.

It just strikes me as risible that my patients seem to excrete spent ammo from time to time.
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  #23  
Old 05-04-2009, 07:49 PM
Chief Pedant Chief Pedant is offline
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Originally Posted by Qadgop the Mercotan View Post
Yep. Only saw one that really looked infected.

It just strikes me as risible that my patients seem to excrete spent ammo from time to time.
Thanks for that word "risible"--I will be using it myself now, on occasion, with the pretense that I knew it all along...
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  #24  
Old 05-04-2009, 08:06 PM
Qadgop the Mercotan Qadgop the Mercotan is online now
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Originally Posted by Chief Pedant View Post
Thanks for that word "risible"--I will be using it myself now, on occasion, with the pretense that I knew it all along...
Excellent! Glad to oblige. Using the term always makes me recall Pontius Pilate in "Life of Brian".

A little french goes a long way, in so many situations.

Try whispering this into your paramour's ear: "Je t'aime! Je t'aime! Maintenant fait le bruit du cochon!" Heightened sensuality will follow!

Unless your paramour understands french.


Last edited by Qadgop the Mercotan; 05-04-2009 at 08:07 PM..
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  #25  
Old 05-04-2009, 09:31 PM
Zsofia Zsofia is online now
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Is there any concern about leaving pieces of metal in the body with the potential that a patient might in the future need an MRI? Or is that not an issue? (I mean, House shot that corpse once to see what would happen and he broke yet another MRI.)
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  #26  
Old 05-04-2009, 10:10 PM
treis treis is offline
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Originally Posted by Chief Pedant View Post
Infection and inflammation are not a problem for the most part if it's just metal.
You would think that the heat of the barrel would sterilize the bullet, right?
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  #27  
Old 05-04-2009, 10:13 PM
Chief Pedant Chief Pedant is offline
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Is there any concern about leaving pieces of metal in the body with the potential that a patient might in the future need an MRI? Or is that not an issue? (I mean, House shot that corpse once to see what would happen and he broke yet another MRI.)
Metal--particularly ferrous metal in some locations can present a problem. However the existence of other imaging techniques means it's not usually by itself sufficient reason to undertake a procedure just to remove metal on the assumption that a patient might someday need an MRI.
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  #28  
Old 05-04-2009, 10:17 PM
Chief Pedant Chief Pedant is offline
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Originally Posted by Dag Otto View Post
Do you know how common it is that pieces of clothing are carried into the wound cavity?
I should have mentioned, for the sake of Doper-level completeness, that nail penetrations through tennis shoes have been felt to be particularly problematic, perhaps because a small amount of tennis shoe foreign body is punched past the skin barrier. Potentially nasty organisms apparently have a predilection for living in tennis shoes. While this is not a weapon-related wound, it's still a penetrating injury.
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  #29  
Old 05-04-2009, 11:52 PM
Mr. Excellent Mr. Excellent is offline
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Originally Posted by Qadgop the Mercotan View Post
Excellent! Glad to oblige. Using the term always makes me recall Pontius Pilate in "Life of Brian".

A little french goes a long way, in so many situations.

Try whispering this into your paramour's ear: "Je t'aime! Je t'aime! Maintenant fait le bruit du cochon!" Heightened sensuality will follow!

Unless your paramour understands french.

Do I have this right?

SPOILER:
I love you! I love you! Now squeal like a pig in heat!
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  #30  
Old 05-05-2009, 08:49 AM
Qadgop the Mercotan Qadgop the Mercotan is online now
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Do I have this right?

SPOILER:
I love you! I love you! Now squeal like a pig in heat!
Not quite.
SPOILER:
I love you! I love you! Now make the pig noise!

treis, bacteria can stand up to a surprising amount of heat, if it's not prolonged. So I'd not count on the bullet to be sterile due do its being fired.
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  #31  
Old 05-05-2009, 09:21 AM
Shot From Guns Shot From Guns is offline
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Originally Posted by Qadgop the Mercotan View Post
Try whispering this into your paramour's ear: "Je t'aime! Je t'aime! Maintenant fait le bruit du cochon!"
Hrm...

SPOILER:
Pig noises or big noises?


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  #32  
Old 05-05-2009, 04:59 PM
Irishman Irishman is offline
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Chief Pedant said:
Quote:
I do not know why Westerns and the like make such an event of digging out the bullet (or arrowhead, for that matter).
Other items like wood (from arrows) or cloth fragments (from clothing) lead to infection. Before antibiotics, there was a noticable correlation between digging out the bullet/arrow and survival.

Quote:
Thousands of asymptomatic soldiers walk around with a great deal of metal in their bodies.
So what are the symptoms of being a soldier?

Qadgop the Mercotan said:
Quote:
Try whispering this into your paramour's ear: "Je t'aime! Je t'aime! Maintenant fait le bruit du cochon!" Heightened sensuality will follow!
Since I can't pronounce French, heightened sensuality is fairly unlikely.
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  #33  
Old 05-05-2009, 11:03 PM
msmith537 msmith537 is offline
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Originally Posted by Zsofia View Post
Is there any concern about leaving pieces of metal in the body with the potential that a patient might in the future need an MRI? Or is that not an issue? (I mean, House shot that corpse once to see what would happen and he broke yet another MRI.)
What would be the issue with an MRI? The bullet isn't going to explode like a piece of foil in the microwave or anything.
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  #34  
Old 05-05-2009, 11:37 PM
Ranchoth Ranchoth is online now
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Originally Posted by msmith537 View Post
What would be the issue with an MRI? The bullet isn't going to explode like a piece of foil in the microwave or anything.
MRI Safety Video (good part starts about 4:10).

Also depends on the composition/jacket of the bullet, naturally.
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  #35  
Old 05-05-2009, 11:59 PM
Bryan Ekers Bryan Ekers is online now
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Originally Posted by Stranger On A Train View Post
Also it is good to leave it in place when you are a world-dominating villain who has been shot in the head with a bullet which is migrating through your brain and will eventually kill you but makes you stronger as it goes on.

I learned this from a Bond film. I also learned that nuclear physicists look like Denise Richards.
You only think they do because the bullet is pressing on the beer-goggle cortex.
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  #36  
Old 08-23-2011, 12:45 AM
bigshooter44 bigshooter44 is offline
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i was shot with an air rifle in the left shoulder

i know its not the same thing as a firearm but the pellet is still inside me and im quite concerned now. its in far to deep for me to just start digging around, it was only a .177 cal pellet. iv narrowed my concern's to tetanus and lead poisoning. i cleaned it out with alcohol and bandaged it with an anti bacterial cream, is there anything else i should do besides go to the doctor? i don't want to have a police report filed because it was one of my friends. its a small town and word travels fast. any help would be greatly appreciated, thanks!
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  #37  
Old 08-23-2011, 01:05 AM
EvilTOJ EvilTOJ is offline
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Go to the doctor and stop posting about it on the internet, geez. If you're worried about it, just say you had your Red Ryder bb gun out and you almost shot your eye out, kid.
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  #38  
Old 08-23-2011, 03:22 AM
clairobscur clairobscur is offline
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is there anything else i should do besides go to the doctor? i don't want to have a police report filed because it was one of my friends.

Do American doctors have to/can report it when they treat a bullet wound? Wouldn't this be covered by medical confidentiality?
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  #39  
Old 08-23-2011, 04:16 AM
constanze constanze is offline
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Cracked article with links. (Nr. 1)
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  #40  
Old 08-23-2011, 08:26 AM
Ferret Herder Ferret Herder is offline
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Do American doctors have to/can report it when they treat a bullet wound? Wouldn't this be covered by medical confidentiality?
Heck, infectious diseases that are a public health concern will get reported to the appropriate state authority; evidence of a crime almost certainly would as well.
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  #41  
Old 08-23-2011, 08:44 AM
muldoonthief muldoonthief is online now
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Originally Posted by clairobscur View Post
Do American doctors have to/can report it when they treat a bullet wound? Wouldn't this be covered by medical confidentiality?
It depends on the state law, but yes, they can be required to report it. Here's the Massachusetts law, and here's the Texas law.
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  #42  
Old 08-23-2011, 09:52 AM
JoelUpchurch JoelUpchurch is offline
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Originally Posted by Qadgop the Mercotan View Post
My patient clientele (prison inmates) tend to extrude bullets at a pretty steady rate. At least 2 or 3 times a year one presents with an old bullet rising to the surface, trying to break out through the skin!

One guy didn't even remember being shot.........
I remember an old saying. If you shoot someone with a 22 and they find out about it, they are going to be pissed. I also had a boss that fell down a flight of stairs and broke his leg and didn't realize it until he sobered up the next day.

Seriously, with arthroscopic surgery how much collateral damage are we talking getting a bullet out, unless it flattened out a lot going in?
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  #43  
Old 08-23-2011, 10:52 AM
Qadgop the Mercotan Qadgop the Mercotan is online now
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Seriously, with arthroscopic surgery how much collateral damage are we talking getting a bullet out, unless it flattened out a lot going in?
Arthroscopic surgery could be great if the bullet happens to be in, you know, a joint. But if it's in muscle or soft tissue or an organ or other body cavities, I wouldn't want to be sticking an arthroscope in there to get it. If it's in the bladder, maybe a cystoscope can pull it out through the urethra, or if it's sitting on top of the spleen or uterus, a laparoscope could pull it out, I suppose.
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  #44  
Old 08-23-2011, 10:55 AM
muldoonthief muldoonthief is online now
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Originally Posted by Qadgop the Mercotan View Post
Arthroscopic surgery could be great if the bullet happens to be in, you know, a joint. But if it's in muscle or soft tissue or an organ or other body cavities, I wouldn't want to be sticking an arthroscope in there to get it. If it's in the bladder, maybe a cystoscope can pull it out through the urethra, or if it's sitting on top of the spleen or uterus, a laparoscope could pull it out, I suppose.
(my bolding). No thank you. Slice me open instead.
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  #45  
Old 08-23-2011, 09:45 PM
bigshooter44 bigshooter44 is offline
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if it was a red ryder i would have cut it out by now, it was a 2000fps varmit rifle. its well into my body... somwere.. doctors tomorrow
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  #46  
Old 08-24-2011, 12:47 AM
Leo Bloom Leo Bloom is offline
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Originally Posted by Qadgop the Mercotan View Post
. ....
Try whispering this into your paramour's ear: "Je t'aime! Je t'aime! Maintenant fait le bruit du cochon!" Heightened sensuality will follow!

Unless your paramour understands french.

It's especially meaningful if you overplay the nasal "o"s, and really get into the pig sound.
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  #47  
Old 08-24-2011, 12:41 PM
Snickers Snickers is offline
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Originally Posted by Qadgop the Mercotan View Post
It just strikes me as risible that my patients seem to excrete spent ammo from time to time.
"No! I was jacking off and I shot the dog!"

One of my favorite jokes.
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  #48  
Old 10-23-2012, 01:05 AM
Dash323 Dash323 is offline
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Originally Posted by Qadgop the Mercotan View Post
My patient clientele (prison inmates) tend to extrude bullets at a pretty steady rate. At least 2 or 3 times a year one presents with an old bullet rising to the surface, trying to break out through the skin!

One guy didn't even remember being shot.........
If a bullet (in my case a .22 no jacket, just lead) is lodged in a muscle or in between muscles (my forearm) does working out the muscles in the area increase the chances of the bullet migrating to the epidermis?
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