A Doctor’s (and EMT’s) Perspective on Gunshot Wounds

One of our readers (thank you Loyd) sent us this video yesterday. While the vast majority of the intro is the anesthesiologist trying (failing?) to give an overview of guns in the United States and then spouting off a TON of relatively useless and irrelevant facts, there are some gems in here about the presentation of gunshot wounds in the emergency environment and their treatment. And while you’re free to watch the video yourself, I thought I’d tease out the important parts and talk about treatment in the field . . .

The #1 thing I took away from this video is something I already knew, specifically that the biggest cause of death from handguns is due to exsanguination (bleeding to death) rather than from the bullet impacting a critical link in the nervous system.

For the self defense shooter, that means even if you hit the guy, best case scenario you’ve probably still got about 10 seconds before they’re combat ineffective. For the recreational shooter, that means having a good first aid kit at hand could be the difference between life and death.

In the pre-hospital environment, the primary goal of gunshot wound management is to stop the bleeding. The average human can lose about a liter of blood before going into hypovolemic shock, and a little over two before having insufficient volume to perfuse adequately through your brain (AKA pretty much dead).

Up until that point your body will systematically shut off blood flow to your extremities, concentrating the remaining volume in your abdomen and head. Which is kinda cool.

For managing that blood loss, it all depends on where the wound is located.

On extremities, people always seem to want to avoid the tourniquet. And sure, for smaller bleeds that can be controlled with direct pressure it might be overkill. But it’s notoriously difficult to identify the severity of a gunshot wound in the field, so my first action is always to grab that TK and slap it on the extremity. Unless that extremity is your head, that is.

From the moment you put it on, you’ve got two hours before you start to see irreversible tissue damage, but that’s still better than the whole “bleeding to death” thing.

For abdominal wounds, it gets a little more complicated. Since there’s so much space in the abdomen for blood to pool, its often extremely difficult to identify just how bad the bleeding is. The larger blood vessels in the abdomen run along the inside of the spine for most of their journey through your body.

That means you won’t typically see any spurting or pulsating flows that would normally indicate a laceration if they have been ruptured. In short, assume the worst. Slap a large trauma pad on there, apply direct pressure and transport immediately.

That right there is the key to survival — immediate transport. Or, as we like to call it, “diesel therapy.” For gunshot wounds, getting the patient to definitive care is the key to survival. Definitive care in this case meaning an operating room — just getting them to the nearest ER is nice, but they need to be sewn back together to survive.

For the civilian, getting someone to definitive care fastest may not mean waiting for an ambulance. Consider that it will take the ambulance between two and five minutes to get the call, an additional two minutes to get rolling, and then it still needs to get from its station to where you’re located.

We’re talking about maybe 10 minutes where you’re bleeding and not getting any closer to the hospital, and that doesn’t even begin to factor in the police having to come and secure the scene before the EMTs roll in.

I may catch hell for this, but if you know where the hospital is located and it’s less than a five minute drive, take the victim yourself. You’ll find that rolling up to the emergency room and yelling “gunshot wound victim” will get you more help than you need to get them on a stretcher and into the ER.

Speaking of rapid transport, something your county may have on hand (which can be very useful if you’re in the middle of nowhere) is a helicopter service. Ambulances can take forever to get to your location and even longer getting back out. A helicopter can often zip in and fly directly to the hospital with much less wasted time.

When you call 911, ask if a helicopter is available — the 911 dispatchers will usually defer to the eyes on the ground (if they sound calm, cool and in control) and dispatch resources as requested. Just be aware that they like a good 50-100 yards (squared) of open field for a landing zone, so if you’re in the woods it might not be an option.

Those are my takeaways from the video, but I just wanted to throw something else in here.

There are a lot of people who stock tampons and quick clot in their bags in case of a gunshot wound, and while those are going to stop the obvious bleeding, they may not stop the actual source of the leak. I’m not going to discourage their use, but I just wanted to remind you guys that just because there’s no gross (obvious) bleeding doesn’t mean the patient isn’t losing tons of blood quickly on the inside.

So, in summary, RAPID TRANSPORT. Worry about the speeding tickets later. And invest in a tourniquet.