Getting shot in the stomach

Factual Questions
21

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:


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.”

22

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?

23

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

24

Thank you, I should have guessed that. Luckily for me, I haven’t “seen” one since the early '70s. :smiley:

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.

  1. 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”.
    ([sub]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[/sub])
    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. :smiley:

25

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.

26

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

27

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?

28

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.

29

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.

30

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.

31

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?

32

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.

33

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.

34

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.

35

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.

36

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.

37

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.

38

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.

39

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. :wink: (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. :slight_smile:

40

Sounds like that’s best bet. Best of luck. :smiley: